P1628ASSESSING CORONARY HEART DISEASE IN SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANTATION - IS THERE SPACE FOR A RISK SCORE MODEL?
Authors: Marques Joana , Pereira Luisa , Messias Ana , Moreira Fonseca Nuno , Cotovio Patrícia , Remédio Francisco , Ferreira Manuel Anibal A , Nolasco Fernando 
Published: June 2020

Abstract

Background and Aims
Type 1 diabetes mellitus (DM1) is associated with an increased risk of coronary heart disease (CHD), which is generally more aggressive and frequently asymptomatic. This risk substantially increases for those with nephropathy. In selected patients, simultaneous pancreas-kidney transplantation (SPKT) is the renal and pancreatic replacement therapy of choice, as it increases longevity and stabilizes diabetic complications. Despite essential, universal screening protocols for silent CHD in this population are still debatable. As so, Gowdak recently developed a simple clinical risk score to determine the pre-test probability of significant CHD in single kidney transplant candidates.
Our aim was to identify potential risk factors associated with the presence of significant lesions on pre-SPKT coronary angiography (CA) and test the utility of Gowdak score in SPKT candidates.

Method
77 patients submitted to SPKT between 2011 and 2018 were retrospectively included in this study. All subjects underwent CA as screening method for CHD during the eligibility evaluation. Demographic, clinical, laboratory, therapeutic and imaging characteristics were studied. Continuous variables are presented as means or medians; categorical variables as frequencies. Univariate analysis (Qui2 or Fisher test) and multivariate analysis (logistic regression) were performed. Comparison between groups of patients with and without CA injury was performed using SPSS statistics version 23 and a p &lt;0.05 was considered significant.

Results
In the past 8 years, 99 SPKT were performed; 78% of these patients (N=77) were submitted to preoperative CA; mean age was 36±5.9 years and 64% were male. The mean duration of DM1 was 25 years and 97% had retinopathy, 43% neuropathy, 31% dysautonomia, 19% peripheral arterial disease and 7% cerebrovascular disease. We excluded 1 due to missing data. A minority of SPKT (3%, N=2) was preemptive. The mean time on dialysis was 37 months. Only one patient had angor, wh0 was excluded of Gowdak risk score assessment. Most patients (87%, N=67) were hypertensive; 56% (N=43) were on statin; 48% (N=37) had smoking habits, and 5% (N=4) had a BMI&gt;30 kg/m2. CA identified at least one lesion in 48% (N = 37) of the patients, of which 30% (N=11; 14% of all CA) underwent intervention; none had complaints of angor. Based on Gowdak risk score, mean probability for CHD was 30.8% and 19 patients had a risk &gt;40% - the recommended cut off to pursuit CA as screening method - but only 2 required intervention. In a univariate analysis, we found that the only distinguishing feature between the group of patients with and without CA lesions was smoking (p=0.005). DM1 with 20 or more years of evolution was found to have a significant association with coronary artery disease development (identifiable by any diagnostic test) (p=0.048). In our population of SPKT recipients Gowdak risk score did not predicted those with significant CHD.

Conclusion
In our study, CA was positive for lesion in almost half of the patients, all of them asymptomatic. Despite the fact that Gowdak probability score failed to identify those with significant CHD before CA (probably because all of our patients were diabetic), in our population for every seven patients submitted to CA, one needed coronary intervention. We highlight that asymptomatic patients with long-term DM and smokers should be carefully evaluated. The task of correctly ascertaining the presence of CAD can be more overwhelming when we take into account that there is a high prevalence of asymptomatic patients with extensive CAD. Facing the importance of an unmissed diagnosis we encourage the use of CA as an initial screening method, even if it is invasive. Further studies should be encouraged to create screening algorithm for SPKT candidates. Finally, medium- and long-term follow-up studies are needed to evaluate the effects of preoperative selection on posttransplant cardiac events and survival rates.