Patient with chronic kidney disease

KEY POINTS

CVD is highly prevalent in patients with CKD. Both conditions seem to worsen each other’s prognosis and complicate most interventions.
The most common cause of death in patients with CKD or on dialysis is CVD.
Patients with CKD often present with nonclassical ischemic heart disease symptoms and require added attention for referral and interpretation of appropriate CAD testing.
Exercise testing in patients with CKD is limited because of a frequent inability to achieve the target heart rate and because the presence of left ventricular hypertrophy (LVH) and associated repolarization changes decrease the specificity of the test.
Radionuclide MPI is an important management tool in this high-risk population.
Like in the general population, abnormal radionuclide MPI identifies high-risk patients.
CKD patients with visually normal myocardial perfusion scans remain at increased risk for CV mortality/morbidity. In patients with visually normal scans, a preserved coronary flow reserve as assessed by PET MPI identifies a low-risk subgroup.
Radionuclide MPI, especially PET MPI, is an effective tool for CAD screening and risk assessment in patients undergoing evaluation for kidney transplant. A normal coronary flow reserve effectively excludes high-risk obstructive CAD and identifies low-risk patients.

Introduction

Chronic kidney disease (CKD) is highly prevalent in the general population, with current estimates at 15% (37 million people) of the U.S. population. Its presence remains associated with a significantly increased risk for cardiovascular (CV) morbidity and mortality, and it often complicates management of CV disease (CVD). Among individuals aged 66 years or older with CKD, the prevalence of CVD is nearly double that of those without CKD (64.5% vs. 32.4%). Specifically, among subjects with CKD, coronary artery disease (CAD) is present in nearly 40%, heart failure in about 30%, and peripheral arterial disease in 25% ( Fig. 15.1 ). In addition, CVD remains the leading cause of death in subjects with CKD, with the risk of all-cause mortality and CV mortality inversely proportional to estimated glomerular filtration rate (eGFR) ( Fig. 15.2 ).

Fig. 15.1, Prevalence of CVD in U.S. patients with or without CKD, 2016.

Fig. 15.2, Hazard ratios (HRs) and 95% confidence intervals CIs for all-cause and cardiovascular mortality according to spline eGFR adjusted for albumin:creatinine ratio, age, gender, race, CVD history, systolic blood pressure, diabetes, smoking, and total cholesterol.

It is important to note that CAD and attendant myocardial ischemia in patients with CKD or end-stage renal disease (ESRD) often lead to atypical presentations. Accordingly, a high degree of suspicion should be maintained in these patients with a high prevalence of CAD, especially with less typical symptoms such as dyspnea or fatigue. Patients can also be completely asymptomatic yet remain at high cardiovascular risk, especially those considered for kidney transplantation. Consequently, diagnosis and risk stratification of known or suspected CAD in patients with CKD and ESRD is important, especially in asymptomatic patients being considered for kidney transplant. In this chapter, we will review the strengths and weaknesses of noninvasive approaches to the evaluation of CAD in this special population with a focus on radionuclide imaging. Technical considerations regarding the radiotracers and protocols, identification and prevention of artifacts, and quantitative assessment of radionuclide images have been reviewed in Chapters 3 , 4 , and 5 . We will also discuss alternative approaches where appropriate.

Patient-centered clinical applications of radionuclide and multimodality imaging in patients with CKD

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