Background. Although consensus guidelines for preoperative cardiovascular (CV) assessment exist, diabetic patients with renal insufficiency (DM/RI) undergoing assessment for renal transplantation are a unique high-risk group that remains poorly investigated. Methods. A consecutive cohort of DM/RI patients being assessed for renal transplantation was studied. We analyzed the ability of clinical characteristics and noninvasive investigation to predict significant coronary artery disease (CAD) and

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... incidence of major adverse CV events. Results. Baseline characteristics (nϭ280) are as follows: mean age 48.6 years (Ϯ11.5 standard deviation), 66% men, diabetes duration 22.6 years (meanϮ8.9 standard deviation), 92% hypertension, 46% hypercholesterolemia, 24% family history CAD, and 21% known CAD. Abnormal myocardial perfusion imaging was found in 27.8%, and 56.5% had CAD more than or equal to 50%. Although positive myocardial perfusion imaging was the only independent predictor of CAD (odds ratio 7.18, 95% confidence interval 2.98 -17.3), a poor negative predicted value was observed with normal imaging in 50.3% of patients having CAD more than or equal to 50%, 35.4% CAD more than 70%, and 41.8% Duke angiographic score more than or equal to 4. At mean follow up of 4 years (median 3.9), 76 of 280 patients suffered major adverse cardiovascular events including 17% mortality. Angiographic evidence of CAD (Ն70% odds ratio 1.81, 95% confidence interval 1.02-3.23) was the only independent predictor of major adverse cardiac events. Conclusion. DM/RI patients being assessed for renal transplantation have frequent CV risk factors, high likelihood of CAD, and a 28% incidence of major adverse cardiac events after 4 years. Myocardial perfusion imagining is of little clinical utility as a screening tool for CAD in this population. Only angiographic CAD was predictive of subsequent major adverse cardiac events. Further studies of risk stratification and revascularization in this high-risk population are warranted.