Prognostic value of myocardial perfusion imaging performed pre-renal transplantation: post-transplantation follow-up and outcomes
Noninvasive stress testing is commonly performed as part of pre-renal transplantation (RT) evaluation. We evaluated the prognostic value of myocardial perfusion imaging (MPI)—myocardial perfusion, left ventricular ejection fraction (LVEF) and heart rate response (HRR)—post-RT.
Consecutive RT recipients were identified at our institution. MPI was considered abnormal when there was a perfusion defect or reduced ejection fraction. HRR to vasodilator stress was calculated as percentage change from baseline. The primary outcome was a composite of cardiovascular (CV) death, myocardial infarction (MI) and coronary revascularization (CR) post-RT; all-cause mortality was the secondary endpoint.
Among 1189 RT recipients, 819 (69%) underwent MPI. Of those, 182 (22%) had abnormal MPI, and 31 (4%) underwent CR pre-RT. During a median follow-up of 56 months post-RT, the annual CV event and mortality rates for patients who had no MPI, normal MPI and abnormal MPI were 1.5%, 3.1% and 4.3% (p < 0.001), and 1.8%, 2.6% and 3.6% (p = 0.016), respectively. After multivariate adjustment, compared to patients without MPI, the hazard ratios (HRs) for CV events for normal and abnormal MPI were 1.47 ([0.93–2.33], p = 0.1) and 1.78 ([1.03–3.06], p = 0.04). Blunted HRR was an independent predictor of CV events (HR = 1.73 [1.04–2.86], p = 0.034) and all-cause death (HR = 2.26 [1.28–3.98], p = 0.005) after adjusting for abnormal MPI. Patients with abnormal MPI who underwent CR pre-RT had annual mortality rates similar to those with no or normal MPI (1.9% vs. 1.7–2.6%, p = 0.2), while those who did not undergo CR had higher annual mortality (4% vs. 1.7–2.6%, p = 0.003).
One in five RT recipients who underwent screening MPI had an abnormal study, an independent predictor of CV events. A blunted HRR to vasodilator stress was associated with increased risk of CV events and death, even after adjusting for abnormal MPI. Patients with abnormal MPI who underwent CR were at low risk of mortality following RT. MPI is a useful tool to aid in risk stratification pre-RT.
KeywordsMyocardial perfusion imaging Renal transplantation Kidney transplantation Outcomes Post-transplantation
American College of Cardiology
American Heart Association
Coronary artery disease
End-stage renal disease
Heart rate response
Left ventricular ejection fraction
Myocardial perfusion imaging
Perfusion defect size
Compliance with ethical standards
Conflict of interest
Drs. Hage and Iskandrian have received research grants from Astellas Pharma USA. All other authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.
- 1.United States Renal Data System. 2016 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. Bethesda: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2016.Google Scholar
- 2.Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL, et al. Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. J Am Coll Cardiol. 2012;60:434–80. https://doi.org/10.1016/j.jacc.2012.05.008.CrossRefPubMedGoogle Scholar
- 7.Doukky R, Fughhi I, Campagnoli T, Wassouf M, Kharouta M, Vij A, et al. Validation of a clinical pathway to assess asymptomatic renal transplant candidates using myocardial perfusion imaging. J Nucl Cardiol. 2017. https://doi.org/10.1007/s12350-017-0901-4.
- 8.AlJaroudi W, Campagnoli T, Fughhi I, Wassouf M, Ali A, Doukky R. Prognostic value of heart rate response during regadenoson stress myocardial perfusion imaging in patients with end stage renal disease. J Nucl Cardiol. 2016;23:560–9. https://doi.org/10.1007/s12350-015-0234-0.CrossRefPubMedGoogle Scholar
- 14.Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227–39. https://doi.org/10.1161/01.CIR.0000133317.49796.0E.CrossRefPubMedGoogle Scholar
- 17.Iqbal FM, Al Jaroudi W, Sanam K, Sweeney A, Heo J, Iskandrian AE, et al. Reclassification of cardiovascular risk in patients with normal myocardial perfusion imaging using heart rate response to vasodilator stress. Am J Cardiol. 2013;111:190–5. https://doi.org/10.1016/j.amjcard.2012.09.013.CrossRefPubMedGoogle Scholar