The incidence of end-stage renal disease is rising and kidney transplantation has been the preferred treatment. This allows for a better quality of life with an overall survival benefit of at least 10 years and good allograft survival of up to 20 years compared to those who remain on dialysis. Most patients with ESRD have multiple co-morbidities hence the importance of proper screening and selection of patients prior to transplant surgery. One of the absolute contraindications for kidney transplantation include severe cardiac or pulmonary disease. An acute cardiovascular event is usually the cause of death with a functioning allograft. Despite severe cardiovascular disease being an absolute contraindication to kidney transplantation, current developments in coronary interventional surgery and aortic aneurysms such as minimally invasive CABG and EVAR, respectively have provided good outcomes for these types of patients allowing for successful and uneventful renal transplantation.

This is a 70-year-old male, diagnosed with ESRD secondary to hypertensive nephrosclerosis, with a history of ischemic heart disease with 3 coronary stents. The patient sought a second chance at a possible transplantation here in the Philippines. His coronary angiogram showed chronic total occlusion of the middle portion of right coronary artery with intercoronary collaterals. Subsequent minimally invasive coronary surgery - coronary artery bypass grafting using left internal mammary artery followed by endovascular aneurysm repair for a 5.1x3.2x3.7cm infrarenal saccular aneurysm on CT aortogram was performed which he tolerated well. After four weeks, he underwent a living-related kidney transplantation with immediate allograft function. The patient made an uneventful recovery and underwent a living kidney donor-transplantation four weeks later. The total vascular anastomosis time was 42 minutes. Serum creatinine improved from 4.6 to as low as 0.6 mg per dL. On postoperative day 5, the patient was unable to void spontaneously. Further workups revealed a low Qmax with significant urine residual on Uroflowmetry with bladder scan. He was diagnosed with benign prostatic obstruction and underwent transurethral resection of the prostate. He tolerated this and voided freely since catheter removal. All throughout this period until one year follow-up the patient had adequate urine output, stable allograft function, and good cardiovascular status.

This strong association between abdominal aortic aneurysms and renal failure remains to be a rate-limiting step in the clearance of potential candidates for renal transplantation. As developments in coronary interventional surgery and aortic aneurysms emerge, these select group of patients are provided the opportunity to undergo renal transplantation with very favorable outcomes.

This case demonstrates that ESRD patients with severe cardiovascular disease may still undergo renal transplantation after a comprehensive pre-operative planning and collaboration with an excellent cardiovascular team. As technological advancements arise, we continue to modify the recipient acceptance criteria and increase the pool of patients for kidney transplantation.