The Pre-Kidney Transplant Cardiovascular Evaluation: A Narrative Review of Current Scientific Statements and Consensus Documents.

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Learn more: PMC Disclaimer | PMC Copyright Notice Cardiol Ther . 2026 Apr 24;15(2):155–170. doi: 10.1007/s40119-026-00448-6 The Pre-Kidney Transplant Cardiovascular Evaluation: A Narrative Review of Current Scientific Statements and Consensus Documents Jacob B Michaud 1 , Gaeth Al-Zaneen 1 , Kim Anderson 2 , Anukul Ghimire 3 , Karthik K Tennankore 1 , Amanda J Vinson 1 , George L Worthen 1, ✉ Author information Article notes Copyright and License information 1 Department of Medicine, Division of Nephrology, Dalhousie University, Nova Scotia Health, 5095 Dickson Building, 5820 University Avenue, Halifax, NS B3H 1V8 Canada 2 Department of Medicine, Division of Cardiology, Dalhousie University, Nova Scotia Health, Halifax, NS Canada 3 Division of Nephrology and the Ajmera Transplant Centre, University Health Network, Toronto, ON Canada ✉ Corresponding author. Received 2026 Feb 23; Accepted 2026 Apr 8; Issue date 2026 Jun. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13221531  PMID: 42030027 Abstract Cardiovascular disease is the leading cause of mortality among individuals with kidney failure, yet evidence-based strategies to reduce cardiovascular risk in this population are limited. Kidney transplantation has been consistently shown to improve survival, including cardiovascular-specific outcomes among those with kidney failure. Substantial heterogeneity exists across transplant centers regarding the pre-transplant cardiovascular evaluation, and the evidence supporting specific testing strategies remains sparse. Current scientific guidelines and consensus statements on pre-kidney transplant cardiovascular assessment, which guide clinical practice, recommend asymptomatic testing in most individuals. However, emerging retrospective evidence suggests limited short-term benefit from routine asymptomatic screening. Ongoing randomized studies may clarify optimal strategies for repeat cardiovascular screening in waitlisted individuals who have undergone initial cardiovascular evaluation. In this review of kidney transplant candidates, we (i) examine contemporary data on cardiovascular screening (ii) highlight the diagnostic limitations of noninvasive testing in kidney failure and the lack of clear benefit from revascularization in the pre-kidney transplant setting, and (iii) outline the consequences of untimely and potentially unnecessary cardiovascular testing. Keywords: Kidney transplantation, Perioperative assessment, Chronic kidney disease Key Summary Points There is significant heterogeneity in practice and limited evidence-based guidance in the pre-kidney transplant cardiovascular evaluation Existing guidelines and statements suggest stress testing for the identification of asymptomatic coronary heart disease in most potential kidney transplant candidates There is no compelling evidence to support revascularization over optimized medical therapy in potential kidney transplant recipients with asymptomatic coronary heart disease Delays in kidney transplantation diminish both cardiovascular and overall morbidity and mortality benefits seen with timely transplantation Open in a new tab Introduction Cardiovascular disease is the leading cause of death in patients with kidney failure [ 1 ]. Up to 80% of patients undergoing hemodialysis have cardiovascular disease, including heart failure (HF), coronary heart disease (CHD), and arrhythmia [ 2 ]. Despite this, evidence-based strategies to lower cardiovascular risk in kidney failure remain limited [ 3 ]. Randomized trials and meta-analyses of single-agent risk-modifying therapies such as statins, beta-blockers, mineralocorticoid receptor antagonists (MRA), or renin-angiotensin system inhibitors (RASi) have not shown consistent and meaningful benefit [ 4 – 7 ]. However, one intervention improves survival in kidney failure: kidney transplantation (KT). KT has been repeatedly shown to increase survival (including cardiovascular survival) compared to remaining on dialysis [ 8 ]; this holds true even among those with documented CHD prior to KT [ 9 ]. Patients with kidney failure hoping to undergo KT must first be evaluated for transplant safety and eligibility to ensure that the benefits of the procedure outweigh the accompanying risks related to surgery and immunosuppression. Given heterogeneity in the approach to pre-transplant cardiovascular risk screening across centers, limited evidence for differences in outcomes with cardiovascular screening, and significant delays in waitlisting associated with untimely pre-KT cardiovascular assessment [ 7 , 10 , 11 ], there is a need for further work in this area. The objectives of this review are to: i. Summarize current scientific statements on the pre-KT cardiovascular evaluation, ii. Highlight new evidence since the publication of these statements, and iii. Outline the risk of delaying KT for the sake of an overly comprehensive cardiovascular workup. Considerations Regarding the Pre-Kidney Transplant Cardiovascular Evaluation Compared with preoperative recommendations for other intermediate-risk elective procedures, current practice statements advocate more intensive preoperative cardiovascular evaluation prior to KT [ 7 , 12 – 14 ]. There are special considerations for solid organ transplantation; notably, potential recipients of kidney allografts are at high risk of cardiovascular events, and kidney allografts remain a scarce resource. Transplant physicians and policymakers try to achieve an optimal balance between equity (i.e., ensuring fair and just access to KT by those who would benefit most) and utility (i.e., efficient use of allografts to ensure maximal graft and patient survival). To increase the latter, the pre-KT cardiovascular evaluation also serves to identify excessive cardiovascular risk that may negatively impact graft survival, over and above the individual’s baseline perioperative risk. Other considerations are outlined in Fig. 1 . Fig. 1. Open in a new tab Special considerations in pre-kidney transplant cardiovascular evaluation. CKD chronic kidney disease, CV cardiovascular, KT kidney transplant Pre-Kidney Transplantation Cardiovascular Screening Suggestions Different organizations have provided guidance on the pre-KT cardiovascular evaluation supported by contemporary data. In this paper, we review (i) the Kidney Disease: Improving Global Outcomes Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation (KDIGO 2020) [ 13 ] for its international appeal, (ii) the Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplant Candidates: A Scientific Statement from the American Heart Association (AHA 2022) [ 7 ] as a large, most updated North American statement, and (iii) the Cardiac evaluation in patients awaiting kidney transplant - position statement of the Cardiological Society of India and Indian Society of Nephrology (CSI/ISN 2025) [ 15 ] as the newest published statement in this field. Although pre-KT workup traditionally focuses on CHD, a substantial proportion of cardiovascular mortality in kidney failure and KT recipients relates to HF, valvular disease, and arrhythmia [ 16 , 17 ]. Therefore, in addition to those pertaining to CHD, we will also synthesize existing consensus recommendations as they pertain to HF, arrhythmia, and valvulopathy. Assessment of Clinically Significant Coronary Heart Disease The main purpose of the pre-KT CHD assessment in individuals without overt symptoms or a history of CHD is to detect clinically significant CHD to (i) identify disease requiring optimized medical therapy (OMT) or revascularization and (ii) identify disease that may increase perioperative morbidity and mortality risk and/or impact kidney allograft longevity. While these goals are useful in theory, there is significant uncertainty in clinical practice. First, there is no consensus on which noninvasive test should be used to identify asymptomatic CHD in patients with kidney failure. Compared with the gold standard invasive coronary angiography, single photon emission computed tomography (SPECT) myocardial perfusion studies (MPS) was relatively specific, but had a sensitivity of only 53% to 66%, whereas coronary computed tomography angiography (CCTA) had a higher sensitivity but a poor specificity of only 63% in potential KT recipients [ 18 – 21 ]. CCTA may be supplemented by fractional flow reserve (FFR-CT) assessment. In one study looking at potential KT recipients, a distal FFR-CT ≤ 0.75 (compared to > 0.8) was associated with increased major adverse cardiac events (MACE) (with an adjusted hazard ratio [HR] of 3.8, 95% confidence interval [95% CI] 1.5 to 9.7), but there was no significant association with mortality. Despite the utility of FFR-CT, its use in potential KT recipients may be limited by the requirement for iodinated contrast, especially in those with residual renal function (RRF) or those not yet requiring dialysis [ 22 ]. In studies evaluating the diagnostic accuracy of a dobutamine stress echocardiography (DSE), sensitivity varied from 44–96% for coronary artery stenosis > 50–70% [ 19 ]. Coronary artery calcium score (CACS) was determined in 438 potential kidney transplant candidates and CACS ≥ 400 were associated with MACE (adjusted HR 2.89, 95% CI 1.23 to 6.78) but not death (adjusted HR 1.94, 95% CI 0.85 to 4.43) when adjusting for traditional risk factors such as age, sex, diabetes, and history of known CHD [ 23 ]. Studies in the non-KT population have suggested that those with excellent functional capacity (> 10 metabolic equivalents [METs]) may be able to forgo cardiac evaluation while those with poor capacity (< 4 METs) may require further testing [ 13 , 24 ]. In the pre-KT population, one Australian study evaluated 898 potential KT recipients who underwent a pre-KT exercise echocardiography. In a multivariable analysis for MACE, they found that while an abnormal echocardiography itself was not associated with increased MACE, achieving predicted METs for age and sex was associated with a reduction in MACE by half. However, KT itself was associated with a significant reduction in MACE and when cumulative MACE was considered over 7 years, outcomes were comparable between those who did and did not achieve target METs prior to KT [ 25 ]. A few small studies have explored the utility of cardiopulmonary exercise testing in the pre-KT evaluation, the largest of which included 240 patients waitlisted for KT and found that patients with an anaerobic threshold of < 40% of predicted peak alveolar oxygen uptake had significantly reduced 5-year overall survival. However, among those with an anaerobic threshold of < 40% of predicted peak alveolar oxygen uptake, KT was still beneficial with non-transplantation associated with increased mortality (HR 4.48, 95% CI 1.78 to 11.36) [ 26 , 27 ]. Data are also inconsistent on whether noninvasive CHD testing accurately predicts cardiovascular outcomes in the pre-KT population. One study found that positive SPECT MPS was not associated with increased fatal and nonfatal cardiovascular events in low-risk individuals (i.e., those younger than 50 years, without diabetes or clinical cardiovascular disease) or in those at high or very high risk (i.e., with two or three risk factors, respectively) undergoing hemodialysis; it was only in those with one single risk factor that positive SPECT MPS findings were associated with a twofold increase in odds of developing future cardiovascular events [ 28 ]. Correlation with invasive angiographic findings and clinical outcomes for common noninvasive testing are presented in Table 1 . Table 1. Performance of noninvasive cardiac tests in relation to coronary angiography and clinical outcomes in potential kidney transplant recipients Clinical test Correlation with angiographic findings Prediction of clinical outcomes SPECT myocardial perfusion studies Sensitivity: 0.66 Specificity 0.75 Reference: 50% and 70% stenosis on coronary angiography [ 21 ] Inconsistent prognostic value; associated with increased MACE in intermediate-risk patients (OR: 2.37, 95% CI 1.69–3.33) [ 28 ] Coronary computed tomography angiography Sensitivity: 0.93 Specificity: 0.63 Reference: > 50% stenosis on coronary angiography [ 20 ] 2-vessel disease associated with MACE (aHR: 2.77, 95% CI 1.26 to 6.11). 3-vessel or left main disease associated with MACE (aHR: 3.84, 95% CI 1.75 to 8.43) and mortality (aHR: 3.30, 95% CI 1.62 to 6.72) [ 23 ] CCTA with fractional flow reserve N/A Distal FFR-CT ≤ 0.75 associated with increased MACE (aHR: 3.8, 95% CI 1.5 to 9.7) but not with mortality [ 22 ] Stress echocardiography Sensitivity: 0.78 Specificity: 0.87 Reference: ≥ 70% stenosis on coronary angiography [ 19 ] Limited data supporting prediction of cardiovascular outcomes in the post-transplant period.[ 25 ] Coronary artery calcium score CACS ≥ 400 Sensitivity: 0.67 Specificity: 0.77 Reference: > 50% stenosis on coronary angiography [ 20 ] High CACS (≥ 400) associated with increased MACE (aHR: 2.89, 95% CI 1.23 to 6.78) but not mortality (aHR: 1.94, 95% CI 0.85 to 4.43) [ 23 ] Achieved METs N/A Higher achieved age- and sex-predicted METs associated with reduced MACE pre-transplant (HR 0.49, 95% CI 0.29 to 0.82) [ 25 ] Cardiopulmonary exercise testing N/A Anaerobic threshold < 40% of VO 2peak associated with reduced 5-year survival (46.6% vs. 94.4%, P < 0.001) [ 26 ] Open in a new tab CT computed tomography, FFR-CT computed tomography-derived fractional flow reserve, CACS coronary artery calcium score, METs metabolic equivalents, VO₂ peak peak alveolar oxygen uptake, MACE major adverse cardiovascular events, OR odds ratio, HR hazard ratio, aHR adjusted hazard ratio, CI confidence interval, N/A not applicable In addition, the ideal management of individuals with CKD and moderate-to-severe CHD as identified by noninvasive testing remains unclear. As we further detail below, the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches–Chronic Kidney Disease (ISCHEMIA-CKD) trial showed no reduction in death or nonfatal myocardial infarction (MI) with routine revascularization over OMT in individuals with an estimated glomerular filtration rate (eGFR) of less than 30 ml/min/1.73 m 2 [ 29 ]. CHD Screening Acknowledging these limitations, in asymptomatic individuals without a known history of CHD, proposed first-line investigations are summarized in Table 2 . Table 2. Criteria for first-line investigations for detection of asymptomatic CHD in patients without a known history of CHD KDIGO 2020 [ 13 ] AHA 2022 [ 7 ] CSI/ISN 2025 [ 15 ] History and examination All 12-lead ECG All Any of: ≥ 40 years old Diabetes Smoking P AD Cerebrovascular disease Dialysis All TTE Any of: ≥ 2 years on dialysis Portal hypertension Connective tissue disease Congenital heart disease COPD Any of: ≥ 40 years old Diabetes Smoking PAD Cerebrovascular disease Dialysis All Noninvasive ischemia testing Any of: Diabetes Poor functional capacity History of CHD Any of: Abnormal TTE Abnormal ECG ≥ 60 years old Diabetes Smoking PAD Cerebrovascular disease ≥ 5 years of kidney replacement therapy (dialysis or KT) History of CHD and last invasive coronary angiography ≥ 1–2 years prior or LVEF < 40% despite ≥ 6 months of OMT Any of: Abnormal TTE Abnormal ECG Diabetes Smoking PAD Cerebrovascular disease Dialysis ≥ 1 year Poor functional capacity History of CHD (or coronary angiography) Coronary angiography Per local guidelines Any of: TTE findings suggestive of CHD Noninvasive testing suggestive of moderate-to-severe CHD Any of: Diabetes (if no noninvasive testing) Noninvasive testing suggestive of moderate-to-severe CHD History of CHD (or noninvasive ischemia testing) Open in a new tab CHD coronary heart disease, COPD chronic obstructive pulmonary disease, ECG electrocardiogram, KT kidney transplantation, LVEF left ventricular ejection fraction, OMT optimal medical therapy, PAD peripheral artery disease, TTE transthoracic echocardiography Management of CHD in the Pre-KT Setting If asymptomatic CHD is identified through screening, the optimal management is not clear. Previous studies of strategies to reduce CHD risk in patients with kidney failure have largely been negative. Earlier randomized controlled studies (RCT) and meta-analyses have suggested benefit in revascularization of asymptomatic CHD in the advanced CKD population but these predate contemporary OMT [ 7 , 30 , 31 ]. The ISCHEMIA-CKD trial compared a composite outcome of death or nonfatal MI in patients with an eGFR of less than 30 mL/min/1.73 m 2 in whom noninvasive testing suggested moderate or severe myocardial ischemia, randomized either to OMT alone or with coronary angiography and revascularization [ 29 ]. Of the 777 patients randomized, 415 (53.4%) were on dialysis for a median of 2 years. For those not receiving dialysis, the median eGFR was 23 ml/min/1.73 m 2 (whereas most transplant centers will not consider patients for kidney transplant referral unless their eGFR is below 15–20 ml/min/1.73). Of the cohort, 48.5% had no symptoms of angina while the others had monthly (39.1%) or more than weekly angina (12.4%). Those with a LVEF < 35%, a history of left main stenosis ≥ 50%, severe valvulopathy, revascularization in the past 12 months, or New York Heart Association (NYHA) class III or IV symptoms were excluded. OMT included lifestyle modification (smoking cessation, physical activity goal ≥ 150 min per week, < 7% of calories from saturated fats, BMI < 25 kg/m 2 ) and medical therapy (blood pressure management to < 130/80 with a beta-blocker, RASi, calcium channel blocker and/or diuretic; LDL-C < 70 mg/dl with a high dose statin and downstream addition of ezetimibe; HbA1c < 8%; anti-anginal therapy with sublingual nitroglycerin, calcium channel blocker, long-acting nitrates or ranolazine; and single antiplatelet therapy). Of 388 participants randomized to the coronary angiography group, 324 (84%) underwent coronary angiography and 190 (49%) underwent revascularization (85% percutaneous, 15% surgical). At a median follow-up of 2.2 years, the estimated 3-year death or nonfatal MI rate was 36% versus 37% (adjusted HR of 1.01, 95% CI 0.79 to 1.29, p = 0.95.), suggesting no benefit of revascularization in this population. While this study did not specifically address pre-KT outcomes, a 2021 post hoc analysis of ISCHEMIA-CKD found that among 194 listed KT candidates, the composite outcome did not differ between invasive and OMT strategies (adjusted HR 0.91, 95% CI 0.54–1.54) [ 32 ]. However, there was significant crossover: 33% of those randomized to OMT alone ultimately underwent coronary angiography within 1 year, 48% of whom were ultimately revascularized. While OMT has been found to be noninferior to revascularization in asymptomatic individuals (with and without CKD) prior to vascular surgery, to our knowledge, no RCT has been performed to evaluate OMT versus coronary angiography with revascularization in the pre-KT population [ 33 , 34 ]. However, a meta-analysis pooling the ISCHEMIA-CKD post hoc analysis and seven observational studies ( n = 945) showed no differences in all-cause mortality (risk ratio [RR] 1.16, 95% CI 0.63–2.12), cardiovascular mortality (RR 0.75, 95% CI 0.29–1.89), or major adverse cardiovascular events (RR 0.78, 95% CI 0.30–2.07) in pre-KT candidates who underwent revascularization versus received OMT alone. Evidence guiding which interventions should constitute OMT in kidney failure is limited. The ISCHEMIA-CKD protocol offers a pragmatic framework adopted by AHA 2022 [ 7 , 32 ]. Since its publication, nonsteroidal MRAs, sodium-glucose cotransporter-2 inhibitors, and glucagon-like peptide-1 receptor agonists have demonstrated cardiovascular benefit in the CKD population, but their use is limited by lack of trial evidence in the kidney failure population [ 35 ]. The Protection against Incidences of Serious Cardiovascular Events Study (PISCES) study may offer a potential new agent; this RCT randomized 1228 participants undergoing hemodialysis (35% of whom had known CHD) to receive either 4 g of fish oil daily or placebo [ 36 ]. There was a significant reduction in the primary composite endpoint of cardiovascular death, nonfatal MI, peripheral vascular disease leading to amputation and nonfatal stroke with event rates of 0.31 versus 0.61 per 1000 patient days in the intervention group (HR 0.57, 95% CI 0.47 to 0.70, p < 0.001.) Despite this significant decrease in cardiovascular endpoints, there was no statistically significant reduction in all-cause mortality (HR 0.89, 95% CI 0.73 to 1.01). Given previous conflicting trials of fish oil in the general population, uptake of this strategy may be cautiously guided by confirmatory studies. While this study did not look specifically at the pre-KT population, it suggests an exciting potential treatment option for cardiovascular risk reduction in a population with limited treatment options [ 37 ]. OMT in pre-KT assessment is presented in Fig. 2 . Fig. 2. Open in a new tab Components of optimized medical therapy in the pre-kidney transplant patient. BMI body mass index, BP blood pressure, GLP-1 glucagon-like peptide-1, HbA1c glycosylated hemoglobin, LDL-C low-density lipoprotein cholesterol, MRA mineralocorticoid receptor antagonist, RAS renin–angiotensin system, SGLT2 sodium-glucose cotransporter-2 Assessment of Heart Failure, Arrhythmia, and Valvulopathy The association between CKD and HF has been well documented, with incidences ranging between 17 and 50% and is associated with at least a twofold increase in mortality [ 38 – 40 ]. CKD-associated HF is multifactorial and driven by volume overload, sympathetic and RAS stimulation, inflammation, uremic toxins, dialysis access (e.g., high output heart failure with arteriovenous fistula), and oxidative stress [ 40 ]. CKD-related HF may also drive the onset of pulmonary hypertension, valvulopathy, and arrhythmia. Heart Failure Assessment of HF in advanced CKD is limited by the unreliability of biomarkers such as B-type natriuretic peptide and by wide variability in volume status in patients undergoing dialysis. Echocardiography is recommended to be done at a euvolemic state for potential KT recipients either at higher risk of HF, with symptoms suggestive of HF, or in all-comers depending on the guideline (see Table 2 ) [ 7 , 13 , 15 ]. As uremic cardiomyopathy is a potentially reversible cause of global left ventricular dysfunction, echocardiography may be repeated in patients with reduced ejection fraction who were clinically uremic and have recently initiated or intensified dialysis. Transplant candidacy for patients with heart failure is debated. KDIGO 2020 advises excluding patients with symptomatic (NYHA class III or IV) and uncorrectable heart failure with severely reduced LVEF (< 30%) from kidney transplantation unless they are considered candidates for heart transplantation [ 41 ]. CSI/ISN 2025 suggests considering patients with reduced ejection fraction for KT if no large areas of non-viable myocardium are identified and they are medically optimized with a beta-blocker, RASi with or without a neprilysin inhibitor, and have achieved euvolemia [ 15 ]. Many studies have reported on improvements in LVEF following KT. In 2005, Wali et al. described a cohort of 15 KT recipients with a preoperative LVEF ≤ 40%, demonstrating improvement in left ventricular function with 70% achieving a post-transplant LVEF ≥ 50% [ 42 ]. Another cohort of 66 KT recipients with preoperative reduced LVEF demonstrated reverse remodeling with an increase in mean LVEF from 41 to 50% ( p < 0.0001) [ 43 ]. Interestingly, while mortality was higher in KT recipients with reduced LVEF compared to those with normal preoperative LVEF, among the subgroup with reduced LVEF who saw a postoperative LVEF increase of ≥ 10%, mortality was not statistically different than that of individuals with a normal baseline LVEF (log-rank = 0.12). Among KT recipients with reduced LVEF, patient factors associated with increased postoperative LVEF include shorter dialysis duration, female sex, post-KT hemoglobin increase, and nonischemic cardiomyopathy (although LVEF improvement in ischemic cardiomyopathy is documented) [ 42 – 45 ]. To our knowledge, no clear guidance exists for KT candidacy in patients with heart failure with preserved ejection fraction (HFpEF). Observational studies of KT recipients have demonstrated that a pre-operative E/e' ratio > 13 was associated with an odds ratio of 1.6 of in-hospital major cardiovascular outcomes (95% CI 1.14 to 2.25) [ 46 ]. This is similar to data reported in the general population [ 12 ]. In addition to poor outcomes associated with HFpEF, management of HFpEF in patients with kidney failure is limited by drug eligibility and a paucity of studies. In cases where HFpEF may be related to obesity, utilization of glucagon-like peptide-1 receptor agonists may be useful [ 47 ]. Otherwise, in the absence of specific pre-KT guidance, it is reasonable to follow guidelines on perioperative management of heart failure with preserved ejection fraction prior to elective surgeries, including medical optimization and symptom management. While most data on cardiac reverse remodeling after KT has focused on LVEF, a few studies have reported on improvement in HFpEF parameters. In a recent study of 42 patients who underwent KT and had echocardiographic assessment obtained prior to KT and at least 3 months post KT, mean E/e' ratio improved from 11.5 to 9.3 ( P = 0.009) with at least 57.1% of participants experiencing an improvement of greater than 10%. Other HFpEF parameters such as left atrial volume index also improved from 32.4 ml/m 2 to 24.3 ml/m 2 ( P = 0.001) [ 48 ]. Pulmonary Hypertension and Tricuspid Regurgitation Pulmonary hypertension (PH) affects approximately one-fourth of patients with kidney failure and is more often linked to hypertensive heart disease and hypervolemia in these populations [ 49 , 50 ]. PH confers increased perioperative mortality in the general population [ 51 ]. In patients with kidney failure, it is associated with poor patient and graft survival; patients with pulmonary artery systolic pressures (PASP) > 35 mmHg had a higher risk of the composite of death, graft failure, or graft dysfunction at 5 years (RR 1.4, 95% CI 1.2 to 1.7, p < 0.001) [ 15 , 41 , 52 ]. However, many studies have reported improvements in PH parameters after KT with one reporting that up to 25% of their observed cohort of 14 patients with pre-KT PASP > 60 mmHg recovered post-KT [ 50 , 53 ]. Both KDIGO 2020 and CSI/ISN 2025 recommended that patients with severe PH (as defined by PASP > 60 mmHg) be evaluated for transplant candidacy on a case-by-case basis, taking into account the etiology of PH and life expectancy [ 15 , 41 ]. Assessment of Valvulopathy There is minimal evidence to guide the assessment of valvulopathy in potential KT recipients. KDIGO 2020 suggests patients be referred to cardiology and managed per local guidelines if they have symptoms suggestive of or documented severe valvular disease [ 41 ]. CSI/ISN 2025 offers specific recommendations summarized in Table 3 [ 15 ]. Table 3. Summary of valvulopathy recommendations by the CSI/ISN 2025 Position Statement [ 15 ] Aortic stenosis Severe aortic stenosis should be managed by surgery or intervention prior to KT Mitral stenosis All patients with severe mitral stenosis should undergo intervention prior to KT. Those with moderate mitral stenosis and symptoms or with a PASP > 50 mmHg should undergo valve intervention prior to KT Mitral regurgitation Asymptomatic patients (including those with severe regurgitation) with normal LVEF may proceed with KT. Presence of severe symptoms or LVEF < 30% predict high risk of adverse outcomes Aortic regurgitation Open in a new tab KT kidney transplant, LVEF left ventricular ejection fraction, PASP pulmonary artery systolic pressure In the absence of specific pre-KT guidance, it is reasonable to use the most up-to-date guidelines on valvulopathy assessment and management prior to elective surgery. Assessment of Arrhythmia While arrhythmia is an increasingly recognized cause of morbidity and mortality in patients with kidney failure [ 54 ], there are limited data to guide the pre-KT assessment of arrhythmias. In nearly all patients, an electrocardiogram is recommended to rule out significant disease (see Table 2 ). However, there are no recommendations to pursue more extensive arrhythmia screening methods in asymptomatic patients with a normal electrocardiogram and no history of arrhythmia. The Predictors of Arrhythmic Events Detected by Implantable Loop Recorders in Hemodialysis Renal Transplant Candidates (PRETRANSPLANT) study followed a cohort of 100 patients undergoing hemodialysis on the KT list with an implantable loop recorder for 8 months and found that 98% had some form of arrhythmia (primarily supraventricular arrhythmia, ventricular arrhythmia, and nonsustained atrial tachycardia), although most were not clinically significant and only five potentially serious arrhythmias were recorded resulting in only one patient referred for pacemaker implantation [ 55 ]. Routine medium-term monitoring in this population is unlikely to be cost-effective or of significant benefit. Risks of Overinclusive Cardiovascular Assessment The pre-KT cardiovascular assessment represents a significant portion of the overall pre-KT workup. Significant delays in waitlisting are associated with testing and potential cardiovascular intervention. In one retrospective study of 1573 KT recipients, median time from referral to KT was 474 days for those without stress testing, 1053 days for those requiring stress testing, and 1687 days for those requiring coronary angiography [ 10 ]. Delays were further increased if patients were revascularized. This observational study, although illustrative, carries significant limitations, especially the risk of confounding by indication. These delays have important impacts on potential KT recipients. First, prolonged time on dialysis is widely recognized as a predictor of poor post-transplant outcomes [ 56 ]. Second, CKD-related HF may be partially reversible following KT, but this benefit is lost with increased time on dialysis [ 15 , 42 ]. Third, overinclusive and excessively long testing may result in the loss of transplant candidacy due to the onset of another medical condition. These factors must be considered when evaluating the value of extensive cardiovascular testing. This is of particular importance in situations of pre-emptive transplantation (i.e., KT prior to dialysis start), living donation (i.e., where there is no deceased donor waitlist and timeline from KT referral to transplantation is much faster), high medical priority (i.e., patients with limited dialysis access options and at high risk of dialysis technique failure), and high sensitization (i.e., those who have alloantibodies markedly restricting the pool of compatible donors). We must consider whether current cardiovascular evaluation patterns, especially those for asymptomatic CHD, are achieving the goal of making transplantation safer by identifying disease where revascularization would affect prognosis and identifying candidates for whom the risk of perioperative complications is too high to justify transplant. Given equipoise between OMT and invasive strategies in ISCHEMIA-CKD, most screen-detected lesions are unlikely to warrant revascularization, aside from high-risk anatomy (e.g., ≥ 50% left main disease, which represented only 2.5% of all coronary angiography findings in this study). In a quasi-experimental analysis of a US cohort using program-level CHD testing rates as an instrumental variable for CHD testing in individual patients, low risk populations (≤ 60 years of age, nondiabetic and without prior CHD) did not have worse outcomes (death or acute MI within 30 days after KT) than those without testing (rate difference 1.9%, 95% CI 0% to 3.5%) [ 57 ]. While not definitive, these findings underline the importance of large prospective trials to evaluate clinical outcomes associated with the pre-KT cardiovascular evaluation. Future Directions The Canadian-Australasian Randomized trial of screening kidney transplant candidates for coronary artery disease (CARSK) study is randomizing asymptomatic patients who have been screened at the time of KT referral to either routine screening or no further screening (provided they remain asymptomatic) while on the waitlist [ 58 ]. At the time of its conception in the late 2010s, 87% of surveyed Canadian KT programs did not support randomization prior to waitlisting as CHD screening was deemed essential to determining medical suitability. The results of CARSK will assist in both determining the interval testing of waitlisted KT candidates and may perhaps help further inform risk in a similar study seeking to randomize individuals prior to initial CHD screening. Recent studies have explored the role of machine learning and artificial intelligence (AI) algorithm aids in the pre-KT evaluation. In one study, data from 518 KT recipients followed over a mean period of 5 years were inputted into machine learning models. They found that along with traditional risk factors (diabetes, angina, dialysis duration, etc.) certain echocardiographic findings (left atrial and right ventricular strain) were associated with post-KT MACE. They also found that machine learning better predicted MACE than traditional statistical models [ 59 ]. Another study evaluated multiple electrocardiography-based AI algorithm in a cohort of 6504 KT recipients, many of whom did not have pre-transplant cardiovascular conditions, and found a high predictive capability for all-cause mortality and cardiovascular death [ 60 ]. However, neither model has been validated outside of their training cohort to date. Conclusions Current contemporary statements and guidelines addressing the pre-kidney transplant cardiovascular evaluation are similar in their recommendations of obtaining noninvasive CHD testing in high-risk, yet asymptomatic, potential kidney transplant recipients. Excessive testing leads to prolonged time to transplantation, which itself is associated with poor post-transplant outcomes. In addition, there is no universally accepted management strategy for CHD if it is detected at the time of testing with growing evidence supporting the effectiveness of OMT and suggesting that revascularization may not always represent the definitive or superior strategy. We have not proposed a singular testing algorithm, rather we have critically synthesized the available evidence. Given the substantial variability in CV testing availability across transplant centers and health systems, clinicians must tailor evaluation within the limitations of their local practice environments, while balancing the diagnostic value of testing against the well-established cardiovascular benefits of timely kidney transplantation. Dedicated prospective studies are needed to further evaluate whether limited asymptomatic testing may benefit potential kidney transplant recipients. Author’s contribution Jacob B Michaud: Performed the literature search and data analysis. Drafted and critically revised the work. Gaeth Al-Zaneen: Drafted and critically revised the work. Kim Anderson: Drafted and critically revised the work. Anukul Ghimire: Drafted and critically revised the work. Karthik K Tennankore: Initial idea for the article. Drafted and critically revised the work. Amanda J Vinson: Drafted and critically revised the work. George L Worthen: Initial idea for the article. Drafted and critically revised the work. Funding No funding or sponsorship was received for this study or publication of this article. Data Availability Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Declarations Conflict of Interest Jacob B Michaud, Gaeth Al-Zaneen, Kim Anderson, Anukul Ghimire, Karthik K Tennankore, Amanda J Vinson and George L Worthen have nothing to disclose. Ethical Approval This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors. References 1. Bhandari SK, Zhou H, Shaw SF, Shi J, Tilluckdharry NS, Rhee CM, et al. Causes of death in end-stage kidney disease: comparison between the United States Renal Data System and a large integrated health care system. Am J Nephrol. 2022;53(1):32–40. 10.1159/000520466. [ DOI ] [ PubMed ] [ Google Scholar ] 2. 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