Meta-analysis finds 2% mean prevalence of class 1 revascularization indications in prekidney transplant CAD screening

KEY POINTS: Coronary artery disease is a barrier to kidney transplantation. Many transplant programs mandate routine coronary artery disease screening. It remains unclear how many patients meet class 1 indication for revascularization. We conducted a meta-analysis to estimate the prevalence. Despite high frequency of screening, we found a relatively low prevalence of class 1 indication for coronary revascularization. BACKGROUND: Cardiovascular disease is the most common cause of morbidity and mortality in kidney transplant recipients. Screening for coronary disease is frequently required before kidney transplantation, but coronary intervention has not been shown to be beneficial except in complex coronary artery disease. The likelihood of finding significant coronary artery disease and the benefits of routine pretransplant screening are uncertain. METHODS: We performed a systematic review and meta-analysis. Medical Literature Analysis and Retrieval System Online and Excerpta Medica database were searched to identify manuscripts published between 1998 and 2024 reporting the results of pretransplant screening. The primary end points were the frequency of detecting significant coronary lesions for which there are American Heart Association class 1 indications for revascularization: ( 1 ) >50% left main stenosis or ( 2 ) multivessel disease with ejection fraction <35% during prekidney transplant screening. Secondary end points included frequency of detecting multivessel disease, proximal left anterior descending artery disease, and number of patients who underwent invasive coronary angiography. Meta-regression was used to explore outcome heterogeneity according to the presence of hypertension, diabetes, and age. RESULTS: We identified 1273 studies, out of which 44 met eligibility criteria. The mean prevalence of class 1 indications was 2%, although the heterogeneity was high with estimates ranging from 0% to 17%. Estimated prevalence of proximal left anterior descending disease was 2% and left main stenosis was 1%, whereas 10% of patients had multivessel coronary artery disease, and 35% were referred for invasive angiography. There was no evidence of significant heterogeneity according to sex of the population or prevalence of diabetes or hypertension. CONCLUSIONS: Identification of class 1 indications for revascularization during pretransplant coronary screening was rare. PODCAST: This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2026_01_08_ASN0000000890.mp3.