The impact of pre-transplant atherosclerosis and coronary artery disease on cardiovascular and graft outcomes in kidney transplant recipients: a systematic review and meta-analysis

Abstract

Background Kidney transplant recipients with pre-existing atherosclerosis or coronary artery disease (CAD) have an increased risk of adverse post-transplant outcomes. However, the extent to which pre-transplant CAD influences mortality, cardiovascular events, and graft function remains unclear. This systematic review and meta-analysis aims to evaluate the impact of pre-existing CAD on all-cause mortality, post-transplant cardiovascular events, and graft failure in kidney transplant recipients. Methods A systematic literature search was conducted using PubMed, Scopus, Web of Science, Cochrane Library, and Ovid MEDLINE. Studies reporting outcomes in kidney transplant recipients with and without pre-existing CAD were included. The primary outcomes were all-cause mortality, major cardiovascular events, and graft failure post-transplantation. Risk estimates were pooled using a random-effects model, with heterogeneity assessed using the I & sup2; statistic. The study protocol was registered with PROSPERO (CRD42024600751). Results A total of 16 studies involving 112,416 kidney transplant recipients were included. Patients with pre-transplant CAD had a significantly higher risk of all-cause mortality compared to those without CAD (hazard ratio [HR] = 1.68, 95% confidence Interval [CI]: 1.38-2.06, P < .01), with high heterogeneity (I & sup2; = 60.0%). The risk of post-transplant cardiovascular events was also significantly increased in patients with CAD (HR = 2.78, 95% CI: 2.00-3.86, P < .01), with moderate heterogeneity (I & sup2; = 36.1%). Graft failure was more common in recipients with pre-transplant CAD, although the effect size was smaller (HR = 1.09, 95% CI: 1.03-1.16, P < .01), with no observed heterogeneity (I & sup2; = 0%). Conclusions Pre-existing CAD in kidney transplant recipients is associated with a significantly increased risk of all-cause mortality and post-transplant cardiovascular events, as well as a modestly but significantly increased risk of graft failure. These findings stress the need for enhanced cardiovascular risk assessment and management strategies in transplant candidates with CAD to improve long-term outcomes.