Vanji Karthikeyan

Coronary risk assessment and management options in chronic kidney disease patients prior to kidney transplantation.

Cardiovascular disease remains the most important cause of morbidity and mortality among kidney transplant recipients. Nearly half the deaths in transplanted patients are attributed to cardiac causes and almost 5% of these deaths occur within the first year after transplantation. The ideal strategies to screen for coronary artery disease (CAD) in chronic kidney disease patients who are evaluated for kidney transplantation (KT) remain controversial. The American Society of Transplantation recommends that patients with diabetes, prior history of ischemic heart disease or an abnormal ECG, or age ≥50 years should be considered as high-risk for CAD and referred for a cardiac stress test and only those with a positive stress test, for coronary angiography. Despite these recommendations, vast variations exist in the way these patients are screened for CAD at different transplant centers. The sensitivity and specificity of noninvasive cardiac tests in CKD patients is much lower than that in the general population. This has prompted the use of direct diagnostic cardiac catheterization in high-risk patients in several transplant centers despite the risks associated with this invasive procedure. No large randomized controlled trials exist to date that address these issues. In this article, we review the existing literature with regards to the available data on cardiovascular risk screening and management options in CKD patients presenting for kidney transplantation and outline a strategy for approach to these patients.

Aortic ring abscess and aortoatrial fistula complicating fulminant prosthetic valve endocarditis due to Proteus mirabilis.

Although gram-negative endocarditis in native valves is uncommon, the frequency of this complication in prosthetic valve patients is increasing. Proteus mirabilis as an etiologic agent of prosthetic valve endocarditis has not been reported before, and only two cases of native valve involvement have been reported with this organism. Our case illustrates the aggressive and fulminant course of Proteus endocarditis and highlights the importance of combining clinical assessment with imaging modalities to plan early surgical intervention in such cases.

Impact of Pre-Existing Left Ventricular Dysfunction on Kidney Transplantation Outcomes: Implications for Patient Selection

BACKGROUND End-stage kidney disease patients with decreased left ventricular ejection fraction (EF) are often denied kidney transplantation (KT) for fear of poor graft and patient survival. METHODS We retrospectively studied all patients who underwent KT at our center between 2001 and 2005 to determine the impact of low EF on outcomes post KT. Low EF was defined as <50% EF by noninvasive cardiac imaging. Follow-up was for 1 year post KT. Outcomes assessed included hospitalization for congestive heart failure (CHF), cardiac events, and renal allograft and patient survival. RESULTS Among 254 patients, 37 had low EF (study group) and 217 had normal EF (≥50%; control group). Post KT, the low EF group had a significantly higher rate of hospitalization for CHF. No significant difference was noted in the rate of cardiac events, graft loss, GFR, and all cause death at 12 months post KT. CONCLUSION Patients with low EF should not be excluded from transplantation, given favorable outcomes.

Complete recovery of acute kidney injury in native kidney following heart kidney transplantation

We report the case of a 23-year-old female who developed severe acute kidney injury (AKI) in the setting of recent onset congestive heart failure secondary to viral cardiomyopathy, cardiogenic shock unresponsive to placement of a biventricular assist device with continued requirement of multiple intravenous pressors, recurrent ventricular tachycardia/fibrillation, and rhabdomyolysis secondary to ischemic necrosis of left leg muscles. Daily slow, low-efficiency dialysis was instituted shortly after admission. Given the possibility of irreversible AKI and the inferior outcomes following heart transplantation alone in patients with perioperative renal dysfunction, she was listed for urgent combined heart-kidney transplantation. Dual transplantation was performed after 9 days of AKI and 7 days on dialysis. Both organs functioned well soon after transplantation. One month post-transplant, recovery of native kidney function with nearly equal contribution to renal function by the native kidneys and the allograft was documented by radioisotopic renography. This case report highlights the difficulty in deciding which patients with severe AKI in the setting of acute heart failure may recover renal function with heart transplantation alone and the need for developing guidelines to help in choosing between heart versus heart-kidney transplantation in such patients.