Cardiovascular Assessment Before Kidney Transplantation: Bridging the Gap Between Guidelines and Clinical Practice

Cardiovascular assessment before kidney transplantation (KT) remains uncertain despite contemporary guidelines. Historically, many transplant centers have adopted intensive screening strategies to detect obstructive coronary artery disease (CAD), often resulting in stress testing, coronary angiography, revascularization, dual antiplatelet therapy, and potentially delayed transplantation. However, evidence that systematic detection and prophylactic treatment of stable CAD improve outcomes in asymptomatic KT candidates remains limited. Recent American, British, and European guidance increasingly supports more selective, risk-adapted assessment, yet the low level of supporting evidence leaves substantial discretion in patient and test selection, as well as wait-list surveillance. This implementation gap is particularly relevant for historically high-testing centers seeking to revise established protocols. Moreover, the cardiovascular phenotype of advanced chronic kidney disease extends beyond obstructive epicardial CAD and includes myocardial, microvascular, structural, and systemic abnormalities that may be better captured by physiological vulnerability and functional reserve. Exercise-based assessment may therefore provide prognostic information beyond ischemia detection. In this Viewpoint, we examine the evidence challenging intensive CAD-centered screening, discuss the evolving role of functional testing and risk-adapted surveillance, and illustrate how these principles were translated into a multidisciplinary local protocol revision. The emerging challenge is not simply to perform fewer tests but to identify who truly benefits from additional testing and to select the right test for the right patient at the right time.