Original ArticlePrognostic implication of myocardial perfusion and contractile reserve in end-stage renal disease: A direct comparison of myocardial perfusion scintigraphy and dobutamine stress echocardiography
Introduction
Chronic kidney disease (CKD) is a severe global health problem1 with a prevalence of approximately 13% of the adult United States population.2 It is generally accepted that a reduced glomerular filtration rate (GFR) and albuminuria are independent risk factors for cardiovascular disease and mortality.3 Importantly, the risk of cardiovascular events increases with declining kidney function, making it more likely to die from a cardiovascular event than to develop end-stage renal disease, ESRD.4,5 Traditional risk factors for coronary artery disease (CAD) such as diabetes mellitus, hypertension, dyslipidaemia, or smoking are frequently present in CKD patients but seem of have less incremental contribution given the underlying severity of their vasculopathy.6 It was suggested that chronic inflammation, Ca+/PO42 regulation disorders, and retention of uremic toxins lead to cardiovascular remodelling different from common atherosclerosis.7, 8, 9 Accordingly, European Guidelines recommend to classify the cardiovascular event risk for patients with a GFR < 30 mL·min−1·1.73 m−2 as very high, regardless of the presence or absence of traditional risk factors.10 This underlines the importance for cardiovascular screening before kidney transplantation (KTx). In this regard, a non-invasive cardiac stress testing is recommended by the current guidelines.11,12 However, the choice of the imaging method is left to the attending physician, primarily because performance and comparability in ESRD cohorts have not been sufficiently explored. MPS and DSE are widely available and affordable imaging modalities that also proved to have a high prognostic impact in cardiovascular risk stratification.13, 14, 15, 16 Coronary angiography (CA) is currently the reference standard for diagnosing epicardial coronary stenoses.17
The aim of this study is to investigate and compare the prognostic value of MPS and DSE in ESRD patients without known CAD who apply for KTx.
Section snippets
Study Design
We prospectively recruited ESRD patients applying for KTx between January 2010 and June 2012 in our centre. Criteria for inclusion were GFR < 20 mL·min−1·1.73 m−2 or need for dialysis and age ≥ 18 years. A systematic analysis of cardiovascular risk factors was performed using structured interviews with a physician, health records, and blood lipid levels. In 230 patients without known ischemic heart disease or typical angina pectoris, MPS and DSE were performed as routine clinical procedures,
Results
Two-hundred twenty-nine ESRD patients without known CAD or typical angina pectoris were evaluated for KTx by MPS and DSE. Table 1 shows baseline characteristics and non-invasive imaging results at the time of screening. Median age was 51 years, the majority of patients were male (57.2%), and the median dialysis vintage was 19 months. Hyperlipidemia (98.3%) and hypertension (96.1%) were very common. Gated SPECT and echocardiography found left ventricular dilation and reduced ejection fractions
Discussion
This study found high cardiovascular morbidity and all-cause mortality in a clinically well-characterized cohort of 229 adult ESRD patients without known CAD or typical angina pectoris at baseline. Long-term follow-up showed that myocardial perfusion defects in stress MPS were a strong predictor of the composite primary endpoint (MI or all-cause death) and the secondary endpoint (MI or CR). WMAs in DSE were also found to be prognostically significant, particularly with respect to the secondary,
New Knowledge Gained
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MPS and DSE reveal a significant incidence of ischemia and myocardial scarring in kidney transplant candidates without known CAD.
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Due to the different pathophysiological parameters measured, MPS and DSE provide complementary but sometimes contradictory information in a significant number of patients.
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Perfusion defects in MPS have a higher prognostic significance for all-cause mortality, MI, and the need for future CR, compared with WMAs in DSE.
Acknowledgments
The authors would like to thank the technicians at the Department of Nuclear Medicine of the University Hospital Münster and Raphael Koch and Dennis Görlich (Institute of Biometry and Clinical Research, University of Münster) for statistical support.
Conflict of interest
Joachim Bautz, Jörg Stypmann, Stefanie Reiermann, Hermann-Joseph Pavenstädt, Barbara Suwelack, Lars Stegger, Kambiz Rahbar, Stefan Reuter and Michael Schäfers declare that they have no conflict of interest.
Ethical Approval
All procedures were in accordance with the
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Cited by (0)
Stefan Reuter and Michael Schäfers: Equal contribution.