LAUSR

Background. Coronary artery disease (CAD) in a kidney transplant candidate is an important predictor of posttransplant mortality. It is not known how the exclusion of CAD in the kidney allocation system has impacted its goal of longevity matching. Methods. This is an observational study on adult deceased donor kidney transplant alone recipients between December 4, 2014, and December 31, 2018, with Medicare fee for service (FFS) insurance. Patients were categorized on the basis of Kidney Donor Profile Index (KDPI), Estimated Posttransplant Survival (EPTS), and CAD. Outcomes studied were mortality, death with a functioning graft, overall graft loss, and death-censored graft loss. Results. Among 21 151 patients with Medicare FFS coverage for >1 y before transplant, there were 2869 and 18 282 patients with and without CAD, respectively. On Kaplan-Meier analysis, there was higher risk of mortality, death with a functioning graft, overall graft loss, and death-censored graft loss with CAD (P < 0.05 for all). Mortality was higher for CAD group within each category of KDPI and among patients with Estimated Posttransplant Survival 0% to 20% receiving kidneys with KDPI <20% (P < 0.001 for all). On Cox multivariate analysis, the hazard ratios (HRs) of mortality and graft loss were higher with CAD diagnosis without intervention (HR 1.38 [1.25-1.52] and 1.29 [1.18-1.4]), CAD with stents (HR 2.76 [1.68-4.53] and 2.36 [1.46-3.81]), and CAD with bypass surgery (HR 1.56 [1.29-1.89] and 1.39 [1.17-1.65]). Posttransplant CAD events were higher in patients with preexisting CAD (P < 0.001). Conclusions. The exclusion of a candidate’s history of CAD in the kidney allocation system adversely impacts its goal of optimal longevity matching.