Reduced myocardial blood flow reserve in kidney transplant candidates may hamper risk stratification

Abstract

Background

Vasodilator nuclear stress testing is frequently ordered for risk stratification prior to kidney transplantation. Since 82Rb-positron emission tomography-computed tomography can measure myocardial blood flow (MBF), the response to vasodilator stress can be verified rendering the results of the scan more reliable.

Methods

We reviewed the MBF response to dipyridamole infusion in 328 patients with end-stage kidney disease (ESKD) prior to transplant (188 hemodialysis-HD, 120 peritoneal dialysis-PD, and 20 pre-dialysis patients-CKD5) and in 100 controls with normal kidney function. A stress/rest MBF ratio ≥ 2 was considered an adequate response to dipyridamole. Coronary artery calcium (CAC) was measured on CT.

Results

Inadequate MBF response was seen in 36%-HD, 21%-PD, 45%-CKD5 vs. 23%-controls (p = 0.006). Univariable predictors of poor MBF response in ESKD patients were age, diabetes mellitus, and CAC (all p < 0.03) while serum hemoglobin was borderline significant (p = 0.052). Multivariable predictors of a poor MBF response were age (p = 0.002) and lower serum hemoglobin (p = 0.014). Ischemia was identified in 8% of ESKD patients and 24% of controls (p < 0.001).

Conclusions

ESKD patients are less likely to respond appropriately to vasodilator stress compared to patients with normal renal function and had a lower incidence of ischemia despite a high pre-test probability of disease. Physicians performing vasodilator stress without MBF measurement should be aware of the high probability of a false negative response.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3

References

  1. 1.

    Lentine KL, Costa SP, Weir MR et al (2012) 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 60:434–480

    Article  Google Scholar 

  2. 2.

    Hakeem A, Bhatti S, Chang SM (2014) Screening and risk stratification of coronary artery disease in end-stage renal disease. JACC Cardiovasc Imaging 7:715–728

    Article  Google Scholar 

  3. 3.

    Carrega L, Fenouillet E, Giaime P et al (2007) Influence of haemodialysis and left ventricular failure on peripheral A(2A) adenosine receptor expression. Nephrol Dial Transpl 22:851–856

    CAS  Article  Google Scholar 

  4. 4.

    Melissinos K, Delidou A, Grammenou S, Markopoulos P (1983) Study of the activity of lymphocyte adenosine deaminase in chronic renal failure. Clin Chim Acta 30(135):9–12

    Article  Google Scholar 

  5. 5.

    Golzar Y, Doukky R (2017) Stress SPECT Myocardial perfusion imaging in end-stage renal disease. Curr Cardiovasc Imaging Rep. https://doi.org/10.1007/s12410-017-9409-1

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Hakeem A, Bhatti S, Dillie KS, Cook JR, Samad Z, Roth-Cline MD et al (2008) Predictive value of myocardial perfusion single-photon emission computed tomography and the impact of renal function on cardiac death. Circulation 118:2540–2549

    Article  Google Scholar 

  7. 7.

    Wilson RF, Wyche K, Christensen BV, Zimmer S, Laxson DD (1990) Effects of adenosine on human coronary arterial circulation. Circulation 82:1595–1606

    CAS  Article  Google Scholar 

  8. 8.

    Budoff MJ, Nasir K, Kinney GL et al (2011) Coronary artery and thoracic calcium on noncontrast thoracic CT scans: comparison of ungated and gated examinations in patients from the COPD Gene cohort. J Cardiovasc Comput Tomogr 5:113–118

    Article  Google Scholar 

  9. 9.

    Kim SM, Chung MJ, Lee KS et al (2008) Coronary calcium screening using low-dose lung cancer screening: effectiveness of MDCT with retrospective reconstruction. AJR Am J Roentgenol 190:917–922

    Article  Google Scholar 

  10. 10.

    Einstein AJ, Johnson LL, Bokhari S, Son J, Thompson RC, Bateman TM, Hayes SW, Berman DS (2010) Agreement of visual estimation of coronary artery calcium from low-dose CT attenuation correction scans in hybrid PET/CT and SPECT/CT with standard Agatston score. J Am Coll Cardiol 56:1914–1921

    Article  Google Scholar 

  11. 11.

    Dilsizian V, Bacharach SL, Beanlands RS et al (2016) ASNC imaging guidelines/SNMMI procedure standard for positron emission tomography (PET) nuclear cardiology procedures. J Nucl Cardiol 23:1187–1226

    Article  Google Scholar 

  12. 12.

    Efseaff M, Klein R, Ziadi MC, Beanlands RS, deKemp RA (2012) Short-term repeatability of resting myocardial blood flow measurements using rubidium-82 PET imaging. J Nucl Cardiol 19:997–1006

    Article  Google Scholar 

  13. 13.

    Dunn OJ (1961) Multiple comparisons among means. J Am Stat Assoc 56(293):52–64

    Article  Google Scholar 

  14. 14.

    Czernin J, Müller P, Chan S et al (1993) Influence of age and hemodynamics on myocardial blood flow and flow reserve. Circulation 88:62–69

    CAS  Article  Google Scholar 

  15. 15.

    Niizuma S, Takiuchi S, Okada S et al (2008) Decreased coronary flow reserve in haemodialysis patients. Nephrol Dial Transpl 23:2324–2328

    Article  Google Scholar 

  16. 16.

    Koivuviita N, Tertti R, Jarvisalo M et al (2009) Increased basal myocardial perfusion in patients with chronic kidney disease without symptomatic coronary artery disease. Nephrol Dial Transpl 24:2773–2779

    Article  Google Scholar 

  17. 17.

    Mahgoub MA, Guo JH, Gao SP et al (1999) Hyperdynamic circulation of arteriovenous fistula preconditions the heart and limits infarct size. Ann Thorac Surg 68:22–28

    CAS  Article  Google Scholar 

  18. 18.

    Marwick TH, Steinmuller DR, Underwood DA, Hobbs RE, Go RT, Swift C, Braun WE (1990) Ineffectiveness of dipyridamole SPECT thallium imaging as a screening technique for coronary artery disease in patients with end-stage renal failure. Transplantation 49:100–103

    CAS  Article  Google Scholar 

  19. 19.

    Holley JL, Fenton RA, Arthur RS (1991) Thallium stress testing does not predict cardiovascular risk in diabetic patients with end-stage renal disease undergoing cadaveric renal transplantation. Am J Med 90:563–570

    CAS  Article  Google Scholar 

  20. 20.

    Herzog CA, Natwick T, Li S, Charytan DM (2019) Comparative utilization and temporal trends in cardiac stress testing in U.S. Medicare beneficiaries with and without chronic kidney disease. JACC Cardiovasc Imaging 12 Pt 1(8):1420–1426

    Article  Google Scholar 

  21. 21.

    Wang LW, Fahim MA, Hayen A et al (2011) Cardiac testing for coronary artery disease in potential kidney transplant recipients. Cochrane Database Syst Rev 12:CD008691

    Google Scholar 

  22. 22.

    Raggi P, Boulay A, Chasan-Taber S et al (2002) Cardiac calcification in adult hemodialysis patients. A link between end-stage renal disease and cardiovascular disease? J Am Coll Cardiol 39:695–701

    Article  Google Scholar 

  23. 23.

    Goodman WG, London G, Amann K et al (2004) Vascular calcification Work Group. Vascular calcification in chronic kidney disease. Am J Kidney Dis 43(3):572–579

    Article  Google Scholar 

  24. 24.

    Sharples EJ, Pereira D, Summers S et al (2004) Coronary artery calcification measured with electron-beam computerized tomography correlates poorly with coronary artery angiography in dialysis patients. Am J Kidney Dis 43:313–319

    Article  Google Scholar 

  25. 25.

    Gewirtz H, Dilsizian V (2016) Integration of quantitative positron emission tomography absolute myocardial blood flow measurements in the clinical management of coronary artery disease. Circulation 133:2180–2196

    Article  Google Scholar 

  26. 26.

    Murthy VL, Naya M, Foster CR et al (2012) Coronary vascular dysfunction and prognosis in patients with chronic kidney disease. JACC Cardiovasc Imaging 5:1025–1034

    Article  Google Scholar 

  27. 27.

    Bellasi A, Raggi P (2012) Vascular imaging in chronic kidney disease. Curr Opin Nephrol Hypertens 21:382–388

    Article  Google Scholar 

  28. 28.

    Winther S, Svensson M, Jørgensen HS et al (2018) Prognostic value of risk factors, calcium score, coronary CTA, myocardial perfusion imaging, and invasive coronary angiography in kidney transplantation candidates. JACC Cardiovasc Imaging 11:842–854

    Article  Google Scholar 

  29. 29.

    Winther S, Svensson M, Jørgensen HS et al (2015) Diagnostic performance of coronary CT angiography and myocardial perfusion imaging in kidney transplantation candidates. JACC Cardiovasc Imaging 8:553–562

    Article  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Paolo Raggi.

Ethics declarations

Conflict of interest

None of the authors have any conflict of interest to disclose.

Research involving human participants

the research was conducted according to the principles of the convention of Helsinki.

Informed consent

The study was approved by the institutional Ethical Review Board; an informed consent from each patient was not deemed necessary since this was a retrospective review of stored medical records.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Malak, M., Christie, E., Wen, K. et al. Reduced myocardial blood flow reserve in kidney transplant candidates may hamper risk stratification. J Nephrol 34, 197–209 (2021). https://doi.org/10.1007/s40620-020-00736-x

Download citation

Keywords

  • Kidney transplantation
  • Risk stratification
  • Hemodialysis
  • Positron emission tomography
  • Myocardial blood flow