Jessica Kameni Muna Simeu
University of Edinburgh, UK
Amin H. Karim MD
Baylor College of Medicine, Houston, Texas
and Houston Methodist Hospital.
Case report
Title: Optimisation of Cardiac Function in patients with Advanced
Kidney Disease in order to Improve Perioperative Risk and Prognosis
of Renal Transplant: A case Report and Review of Literature
Case Summary:
A 63-year-old African American woman with type II diabetes mellitus, diabetic nephropathy, and retinopathy presented with multiple cardiovascular risk factors, including hypertension, hyperlipidaemia, obesity, and advanced chronic kidney disease requiring thrice-weekly dialysis. Echocardiography demonstrated concentric left ventricular hypertrophy, left atrial dilation, and a preserved ejection fraction of 60–65%, consistent with heart failure with preserved ejection fraction (HFpEF). Cardiac catheterisation revealed significant three-vessel coronary artery disease involving the RCA, LAD, and ostial ramus artery. She subsequently underwent coronary artery bypass grafting (CABG), with marked improvement in left ventricular function on follow-up echocardiography. This case highlights the importance of comprehensive cardiovascular assessment prior to renal transplantation, particularly in patients with multiple cardiovascular risk factors and advanced kidney disease. Identification and optimisation of significant cardiovascular disease prior to transplantation improves perioperative risk stratification and long-term patient and allograft outcomes.
Discussion
Chronic kidney disease is an emerging major public health problem worldwide, [1] with cardiovascular disease (CVD) representing the primary cause of death in patients with advanced chronic kidney disease (CKD) or end-stage renal disease (ESRD). Compared to maintenance dialysis, kidney transplantation significantly improves survival and quality of life. [2] Among patients receiving renal replacement therapy (RRT), cardiac deaths account for 40–50% of total mortality, with 10–20% attributable to acute coronary events. [1] The risk of major adverse cardiac events (MACE) remains relatively constant while on the transplant waiting list, increases markedly in the early post-transplant period, and declines at a slower rate thereafter. These dynamics emphasize the necessity of managing coronary artery risk factors and mandate CVD screening during pre-transplant evaluations to stratify both perioperative risk and early post-transplant outcomes. [2]
Although this patient had multiple risk factors, she remained clinically asymptomatic—denying chest pain, syncope, palpitations, or dyspnea despite severe coronary artery disease (>70% stenosis across three major vessels). Initial echocardiography showed mild concentric LVH, mild left atrial dilation, and preserved LV systolic function (LVEF 60–65%). Subsequent cardiac catheterisation in September 2025 demonstrated severe multivessel CAD: 70–80% stenosis of the LAD, 60–70% of the RCA, and 70–80% of the ostial ramus. These findings underscore the necessity of diagnostic catheterisation in asymptomatic, high-risk candidates. Traditional CAD risk factors (hypertension, diabetes, dyslipidaemia, and smoking) substantially increase both CKD prevalence and CVD severity. [2]
Renal transplantation confers a major survival advantage over long-term dialysis. [3] Because cardiovascular disease remains the leading cause of post-transplant morbidity and mortality, pre-transplant evaluation aims to uncover occult disease, stratify risk, and optimize modifiable factors. Patients with ESRD face disproportionate risk due to concurrent diabetes, hypertension, dyslipidaemia, volume overload, and uraemia, necessitating pre-transplant revascularization when severe CAD is present.
The patient underwent CABG on February 10, 2026. Postoperative echocardiography revealed a hyperdynamic left ventricle with preserved right ventricular function. Recovery was complicated by a small provoked pulmonary embolism 10 days postoperatively, treated with six months of anticoagulation; follow-up ECG demonstrated normal sinus rhythm without ischaemia. This functional recovery aligns with data from Papestiev et al., [4] demonstrating that myocardial systolic and diastolic function can improve following CABG even in patients with preserved preoperative LVEF. Beyond surgical revascularisation, pre-transplant optimisation addressed blood pressure control (systolic BP consistently <140 mmHg), glycaemic management (HbA1c 5.3%), dyslipidaemia, weight management, and structured cardiac rehabilitation.
Conclusion
This case highlights the essential role of systematic cardiovascular screening in advanced CKD regardless of symptom status. ESRD remains an independent predictor of severe cardiovascular morbidity and mortality. Because kidney transplantation offers superior life expectancy, quality of life, and cost-effectiveness compared with dialysis, eligible candidates must be prioritized for pre-transplant cardiovascular optimisation. Early detection and revascularisation restore myocardial performance, improve perioperative safety, and support successful progression to renal transplantation.
References
Papestiev V, Jovev S, Risteski P, Popov AF, Sokarovski M, Andova V, et al. Myocardial function after coronary artery bypass grafting in patients with preoperative preserved left ventricular ejection fraction—the role of the left ventricular longitudinal strain. Medicina (Kaunas). 2023;59(5):932. MDPI
Yadav V, Jha SC, Gajurel RM, Poudel CM, Sahi R, Sharma M, Adhikari S. Spectrum of coronary angiographic findings in potential renal transplant recipients in a tertiary care center of Nepal. Transplant Res Risk Manag. 2020;12:15-22. ProQuest
Ewing EC, Edwards AR. Cardiovascular disease assessment prior to kidney transplantation. Methodist DeBakey Cardiovasc J. 2022;18(4):50-61. PubMed Central
Kanbay M, Abdel-Rahman SM, Brinza C, Ozbek L, Yayci E, Aktas O, et al. A meta-analysis of graft survival, patient survival and delayed graft function in first-time and repeat kidney transplants. Nephrol Dial Transplant. 2025;40(10):1906-1918. Oxford Academic
Links
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