Date of Award

January 2026

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Michael G. Nanna

Abstract

BackgroundKidney and liver transplantation significantly improve life expectancy and quality of life in patients with end-stage renal disease (ESRD) or end-stage liver disease (ESLD). Due to the scarcity of organs, transplant centers face high scrutiny of outcomes and employ thorough preoperative evaluation for potential candidates. Patients with ESRD and ESLD often have high comorbidity burdens, including coronary artery disease (CAD), and since transplant is a major surgery, evaluating and reducing cardiac risk is a key component of preoperative evaluation and optimization. However, the role of coronary revascularization in transplant candidates with stable CAD is uncertain, leading to variation in clinical practice. Data informing current guidelines have a variety of limitations, including studies focused on other types of surgery, studies including transplant recipients rather than all candidates, and low detail of coronary lesions and dual antiplatelet therapy (DAPT) regimens after intervention. Research aims This study aims to evaluate the impact of coronary revascularization and subsequent DAPT regimens on listing for transplant, receipt of transplant, and perioperative and long-term mortality and major adverse cardiac events (MACE), while also characterizing cardiac evaluation and management practices in patients undergoing evaluation for kidney or liver transplantation. Question In adult patients with stable CAD undergoing kidney or liver transplant evaluation, does coronary revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG]) compared to no revascularization improve the likelihood of transplant listing and receipt of transplant, and reduce perioperative and long-term mortality and MACE? Methods/Approach This is a single-center retrospective study of all adult patients (age 18+) at Yale- New Haven Hospital (YNHH) evaluated for kidney or liver transplant between 1/1/2013 and 10/31/2025. All data were collected from the YNHH electronic medical record. Patients were identified by the Phoenix Module. Patient demographics; list status, dates, and outcomes; transplant status and dates were collected through Phoenix. Additional data, including comorbidities, cardiac evaluation dates and results, medications specifically including DAPT regimen if applicable, and clinical outcomes including mortality and MACE were collected by manual chart review. A preliminary proof-of- concept analysis was performed for a subset of 10 liver transplant candidates evaluated in early 2022 to assess feasibility and data granularity. Results Across the full cohort, 7,475 patients were evaluated for transplantation, including 2,386 liver and 5,089 kidney transplant candidates. Kidney transplant candidates were waitlisted and transplanted more frequently compared to liver transplant candidates. In the preliminary cohort of 10 liver transplant cases, cardiac evaluation commonly included echocardiography, pharmacologic stress testing, and invasive coronary angiography. These tests were typically completed within 3 to 5 months of the initial transplant evaluation. One patient was newly diagnosed with severe CAD and received revascularization of the left main coronary artery via PCI. Another patient was found to have non-obstructive CAD. These cases demonstrate the level of clinical detail obtainable via structured chart review. For the full cohort, planned analyses of the full cohort include comparisons of primary outcomes between revascularized and non-revascularized groups. Stratified analyses by severity of CAD and type of intervention (PCI vs CABG, duration of DAPT) will be conducted. All analyses will be performed separately between kidney and liver transplant candidates. Statement of scientific impact This study demonstrates the feasibility of constructing a high-detail dataset of cardiovascular evaluation and management of liver and kidney transplant candidates. By analyzing cardiac evaluation and intervention with high precision in this population, this study may shed further light on the utility of revascularization in patients evaluated for transplant, aiding complex decision-making and improving patient care in this vulnerable population.

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This is an Open Access Thesis.

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