Page 6 - Cardiac testing for coronary artery disease in potential kidney transplant recipients

2. Indirect comparison: By comparing the pooled results of Exclusion criteria
studies that assessed accuracy of screening tests in separate Studies were excluded if they did not explicitly state that all study
populations.
participants were candidates for kidney transplantation. We also
The ability of screening tests to detect severe coronary artery steno- excluded studies that investigated cardiac test accuracy in patients
sis (≥ 70% stenosis detected on coronary angiography) was also
with ESKD who were not transplant candidates (i.e. they were
assessed and compared among different screening tests. unselected dialysis patients, not undergoing pre-transplant assess-
ment). Patients with ESKD who are not transplantation candi-
dates differ from patients who are transplant candidates with re-
spect to several key prognostic variables, such as age and fitness for
Investigation of sources of heterogeneity
surgery. These differences in the key prognostic variables may re-
We also investigated if diagnostic accuracy varied among studies sult in differences in disease prevalence and test performance. We
with different prevalence of symptomatic chest pain and analysed also excluded studies which investigated patients with features of
the effect. For this analysis, we included only studies that used acute coronary syndrome as our aim was to investigate the perfor-
a threshold of ≥ 70% stenosis on coronary angiography for the mance of cardiac tests in a preoperative screening context. Where
diagnosis of CAD. To avoid partial verification, we considered it appeared that only some of the study participants were trans-
effects among study participants who underwent both the index plantation candidates, we contacted the study authors requesting
test and coronary angiography. This methodology meant that we separate data for only transplantation candidates.
were able to avoid partial verification.
Index tests
Any non- or minimally invasive test used to assess risk of CAD.
These included:
M E T H O D S • Stress echocardiography (using either exercise or
pharmacological stress, e.g. DSE)
• MPS using either exercise or pharmacological stress
• EST
Criteria for considering studies for this review • EBCT
• ECG
• Conventional echocardiography
• Exercise ventriculography
Types of studies
• DSF
We included all diagnostic cross sectional studies, cohort studies • CIMT
and randomised studies of test accuracy that compared cardiac test • Cardiopulmonary exercise testing
accuracy with results obtained from coronary angiography (the • CT coronary angiography
reference standard). • Magnetic resonance angiography
• Cardiac magnetic resonance imaging.
Information regarding the various index tests including the type of
Participants
result produced, if cut-off values were present, and how differences
Study participants included all patients who were considered to be in cut-off points were handled, is provided in Table 1.
potential candidates for kidney transplantation or kidney-pancreas
transplantation at the time the diagnostic tests were performed.
Comparator tests
Any of the listed index tests where they were compared with each
Inclusion criteria other versus the reference standard of coronary angiography.
We included studies reporting outcomes relating to patients con-
sidered to be potential candidates for kidney transplantation or
Target conditions
kidney-pancreas transplantation at the time diagnostic tests were
performed. To ensure that our review was accessible and succinct, Coronary artery stenosis was defined as at least 50% narrowing in
we chose to limit the population to patients with CKD who were at least one epicardial coronary artery on coronary angiography.
considered candidates for kidney transplantation, but included all We defined severe coronary artery stenosis as ≥ 70% stenosis on
possible tests used to diagnose CAD. coronary angiography.

Cardiac testing for coronary artery disease in potential kidney transplant recipients (Review) 4
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.