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Huck DM, Weber B, Schreiber B, Pandav J, Parks S, Hainer J, Brown JM, Divakaran S, Blankstein R, Dorbala S, Trinquart L, Chandraker A, Di Carli MF. Comparative Effectiveness of PET and SPECT MPI for Predicting Cardiovascular Events After Kidney Transplant. Circ Cardiovasc Imaging 2024; 17:e015858. [PMID: 38227694 PMCID: PMC10794031 DOI: 10.1161/circimaging.123.015858] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/08/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Advanced chronic kidney disease is associated with high cardiovascular risk, even after kidney transplant. Pretransplant cardiac testing may identify patients who require additional assessment before transplant or would benefit from risk optimization. The objective of the current study was to determine the relative prognostic utility of pretransplant positron emission tomography (PET) and single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) for posttransplant major adverse cardiovascular events (MACEs). METHODS We retrospectively followed patients who underwent MPI before kidney transplant for the occurrence of MACE after transplant including myocardial infarction, stroke, heart failure, and cardiac death. An abnormal MPI result was defined as a total perfusion deficit >5% of the myocardium. To determine associations of MPI results with MACE, we utilized Cox hazard regression with propensity weighting for PET versus SPECT with model factors, including demographics and cardiovascular risk factors. RESULTS A total of 393 patients underwent MPI (208 PET and 185 SPECT) and were followed for a median of 5.9 years post-transplant. Most were male (58%), median age was 58 years, and there was a high burden of hypertension (88%) and diabetes (33%). A minority had abnormal MPI (n=58, 15%). In propensity-weighted hazard regression, abnormal PET result was associated with posttransplant MACE (hazard ratio, 3.02 [95% CI, 1.78-5.11]; P<0.001), while there was insufficient evidence of an association of abnormal SPECT result with MACE (1.39 [95% CI, 0.72-2.66]; P=0.33). The explained relative risk of the PET result was higher than the SPECT result (R2 0.086 versus 0.007). Normal PET was associated with the lowest risk of MACE (2.2%/year versus 3.6%/year for normal SPECT; P<0.001). CONCLUSIONS Kidney transplant recipients are at high cardiovascular risk, despite a minority having obstructive coronary artery disease on MPI. PET MPI findings predict posttransplant MACE. Normal PET may better discriminate lower risk patients compared with normal SPECT, which should be confirmed in a larger prospective study.
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Affiliation(s)
- Daniel M Huck
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brittany Weber
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brittany Schreiber
- Division of Nephrology (B.S., J.P., A.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jay Pandav
- Division of Nephrology (B.S., J.P., A.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sean Parks
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jon Hainer
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jenifer M Brown
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sanjay Divakaran
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ron Blankstein
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sharmila Dorbala
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ludovic Trinquart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (L.T.)
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA (L.T.)
| | - Anil Chandraker
- Division of Nephrology (B.S., J.P., A.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marcelo F Di Carli
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Echefu G, Stowe I, Burka S, Basu-Ray I, Kumbala D. Pathophysiological concepts and screening of cardiovascular disease in dialysis patients. FRONTIERS IN NEPHROLOGY 2023; 3:1198560. [PMID: 37840653 PMCID: PMC10570458 DOI: 10.3389/fneph.2023.1198560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/10/2023] [Indexed: 10/17/2023]
Abstract
Dialysis patients experience 10-20 times higher cardiovascular mortality than the general population. The high burden of both conventional and nontraditional risk factors attributable to loss of renal function can explain higher rates of cardiovascular disease (CVD) morbidity and death among dialysis patients. As renal function declines, uremic toxins accumulate in the blood and disrupt cell function, causing cardiovascular damage. Hemodialysis patients have many cardiovascular complications, including sudden cardiac death. Peritoneal dialysis puts dialysis patients with end-stage renal disease at increased risk of CVD complications and emergency hospitalization. The current standard of care in this population is based on observational data, which has a high potential for bias due to the paucity of dedicated randomized clinical trials. Furthermore, guidelines lack specific guidelines for these patients, often inferring them from non-dialysis patient trials. A crucial step in the prevention and treatment of CVD would be to gain better knowledge of the influence of these predisposing risk factors. This review highlights the current evidence regarding the influence of advanced chronic disease on the cardiovascular system in patients undergoing renal dialysis.
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Affiliation(s)
- Gift Echefu
- Division of Cardiovascular Medicine, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ifeoluwa Stowe
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, United States
| | - Semenawit Burka
- Department of Internal Medicine, University of Texas Rio Grande Valley, McAllen, TX, United States
| | - Indranill Basu-Ray
- Department of Cardiology, Memphis Veterans Affairs (VA) Medical Center, Memphis, TN, United States
| | - Damodar Kumbala
- Nephrology Division, Renal Associates of Baton Rouge, Baton Rouge, LA, United States
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Gao P, Zou X, Sun X, Zhang C. Coronary Artery Disease in CKD-G5D Patients: An Update. Rev Cardiovasc Med 2023; 24:227. [PMID: 39076724 PMCID: PMC11266819 DOI: 10.31083/j.rcm2408227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 02/21/2023] [Accepted: 02/28/2023] [Indexed: 07/31/2024] Open
Abstract
Patients with chronic kidney disease treated by dialysis (CKD-G5D) are characterized by a high prevalence of coronary artery disease (CAD). Such patients differ from non-uremic CAD patients and have been excluded from several clinical CAD trials. CKD-G5D patients may be asymptomatic for their CAD, making their risk stratification and management challenging. This review will focus on the incidence, epidemiology, pathophysiology, screening tools, and management/treatment of CAD in CKD-G5D patients. It will also review recent studies concerning the screening tools and management strategies available for these patients. The need for improved evaluation of cardiovascular risk factors, screening and early intervention for symptomatic CAD in CKD-G5D patients will be highlighted.
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Affiliation(s)
- Pan Gao
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Technology, 430022 Wuhan, Hubei, China
| | - Xingjian Zou
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Technology, 430022 Wuhan, Hubei, China
| | - Xin Sun
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Technology, 430022 Wuhan, Hubei, China
| | - Chun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Technology, 430022 Wuhan, Hubei, China
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Pezel T, Unterseeh T, Hovasse T, Sanguineti F, Garot P, Champagne S, Toupin S, Ah-Sing T, Faradji A, Nicol M, Hamzi L, Dillinger JG, Henry P, Bousson V, Garot J. Safety and incremental prognostic value of stress cardiovascular magnetic resonance in patients with known chronic kidney disease. J Cardiovasc Magn Reson 2023; 25:29. [PMID: 37308923 PMCID: PMC10259036 DOI: 10.1186/s12968-023-00939-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 05/15/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is the main cause of mortality in patients with chronic kidney disease (CKD). Although several studies have demonstrated the consistently high prognostic value of stress cardiovascular magnetic resonance (CMR), its prognostic value in patients with CKD is not well established. We aimed to assess the safety and the incremental prognostic value of vasodilator stress perfusion CMR in consecutive symptomatic patients with known CKD. METHODS Between 2008 and 2021, we conducted a retrospective dual center study with all consecutive symptomatic patients with known stage 3 CKD, defined by estimated glomerular filtration rate (eGFR) between 30 and 60 ml/min/1.73 m2, referred for vasodilator stress CMR. All patients with eGFR < 30 ml/min/1.73 m2 (n = 62) were excluded due the risk of nephrogenic systemic fibrosis. All patients were followed for the occurrence of major adverse cardiovascular events (MACE) defined as cardiac death or recurrent nonfatal myocardial infarction (MI). Cox regression analysis was used to determine the prognostic value of stress CMR parameters. RESULTS Of 825 patients with known CKD (71.4 ± 8.8 years, 70% men), 769 (93%) completed the CMR protocol. Follow-up was available in 702 (91%) (median follow-up 6.4 (4.0-8.2) years). Stress CMR was well tolerated without occurrence of death or severe adverse event related to the injection of gadolinium or cases of nephrogenic systemic fibrosis. The presence of inducible ischemia was associated with the occurrence of MACE (hazard ratio [HR] 12.50; 95% confidence interval [CI] 7.50-20.8; p < 0.001). In multivariable analysis, ischemia and late gadolinium enhancement were independent predictors of MACE (HR 15.5; 95% CI 7.72 to 30.9; and HR 4.67 [95% CI 2.83-7.68]; respectively, both p < 0.001). After adjustment, stress CMR findings showed the best improvement in model discrimination and reclassification above traditional risk factors (C-statistic improvement: 0.13; NRI = 0.477; IDI = 0.049). CONCLUSIONS In patients with known stage 3 CKD, stress CMR is safe and its findings have an incremental prognostic value to predict MACE over traditional risk factors.
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Affiliation(s)
- Théo Pezel
- Université de Paris Cité, Service de Cardiologie, Hôpital Lariboisière-APHP, Inserm UMRS 942, 75010, Paris, France
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
- Université de Paris Cité, Service de Radiologie, Hôpital Lariboisière-APHP, 75010, Paris, France
| | - Thierry Unterseeh
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Thomas Hovasse
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Francesca Sanguineti
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Philippe Garot
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Stéphane Champagne
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Solenn Toupin
- Siemens Healthcare France, 93200, Saint-Denis, France
| | - Tania Ah-Sing
- Université de Paris Cité, Service de Radiologie, Hôpital Lariboisière-APHP, 75010, Paris, France
| | - Alyssa Faradji
- Université de Paris Cité, Service de Radiologie, Hôpital Lariboisière-APHP, 75010, Paris, France
| | - Martin Nicol
- Université de Paris Cité, Service de Cardiologie, Hôpital Lariboisière-APHP, Inserm UMRS 942, 75010, Paris, France
- Université de Paris Cité, Service de Radiologie, Hôpital Lariboisière-APHP, 75010, Paris, France
| | - Lounis Hamzi
- Université de Paris Cité, Service de Radiologie, Hôpital Lariboisière-APHP, 75010, Paris, France
| | - Jean Guillaume Dillinger
- Université de Paris Cité, Service de Cardiologie, Hôpital Lariboisière-APHP, Inserm UMRS 942, 75010, Paris, France
| | - Patrick Henry
- Université de Paris Cité, Service de Cardiologie, Hôpital Lariboisière-APHP, Inserm UMRS 942, 75010, Paris, France
| | - Valérie Bousson
- Université de Paris Cité, Service de Radiologie, Hôpital Lariboisière-APHP, 75010, Paris, France
| | - Jérôme Garot
- CMR Department-ICPS, Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques CARTIER, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
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Hirsch D, Lau B, Kushwaha V, Yong K. The Controversies of Coronary Artery Disease in End-Stage Kidney Disease Patients: A Narrative Review. Rev Cardiovasc Med 2023; 24:181. [PMID: 39077541 PMCID: PMC11264163 DOI: 10.31083/j.rcm2406181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 07/31/2024] Open
Abstract
Cardiovascular disease (CVD) accounts for more than 50% of deaths among patients with end-stage kidney disease (ESKD). Approximately 40-50% of ESKD patients have clinically significant coronary artery disease (CAD) due to atherosclerosis which accounts for a significant proportion of CVD risk. However, other CVD pathologies including myocardial fibrosis, vascular calcification and arterial stiffening play important contributory roles. The pathophysiology of CAD in ESKD is distinct from the general population. ESKD patients is typically have diffuse multi-vessel involvement with increased calcification that involves both intimal and medial layers of the arterial wall. There is a complex interplay between an increased burden of traditional Framingham risk factors and exposure to non-traditional risk factors including chronic inflammation and dialysis per se. Established treatments for CAD risk factors including cholesterol lowering with statin therapy have attenuated effects and ESKD patients also have worse outcomes after revascularisation. Recent trials such as the Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS) have established that direct modulation of inflammation improves CVD outcomes in the general population, which may prove to be a potential attractive therapeutic target in ESKD patients. Multiple retrospective observational studies comparing mortality outcomes between haemodialysis (HD) and peritoneal dialysis (PD) patients have been inconclusive. Randomised trials on this issue of clinical equipoise are clearly warranted but are unlikely to be feasible. Screening for stable CAD in asymptomatic ESKD patients remains a clinical dilemma which is unique to chronic dialysis patients being assessed for kidney transplantation. This has become particularly relevant in light of the recent ISCHEMIA-CKD trial which demonstrated no difference between optimal medical therapy and revascularisation upon CVD outcomes or mortality. The optimal strategy for screening is currently being investigated in the ongoing large international multi-centre CARSK trial. Here we discuss the pathophysiology, risk modification, treatment, screening and future directions of CAD in ESKD.
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Affiliation(s)
- Daniel Hirsch
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW 2031, Australia
- Prince of Wales Clinical School, University of New South Wales, Kensington, NSW 2033, Australia
| | - Brandon Lau
- Prince of Wales Clinical School, University of New South Wales, Kensington, NSW 2033, Australia
| | - Virag Kushwaha
- Prince of Wales Clinical School, University of New South Wales, Kensington, NSW 2033, Australia
- Department of Cardiology, Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Kenneth Yong
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW 2031, Australia
- Prince of Wales Clinical School, University of New South Wales, Kensington, NSW 2033, Australia
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Cheng XS, VanWagner LB, Costa SP, Axelrod DA, Bangalore S, Norman SP, Herzog C, Lentine KL. Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association: Endorsed by the American Society of Transplantation. Circulation 2022; 146:e299-e324. [PMID: 36252095 PMCID: PMC10124159 DOI: 10.1161/cir.0000000000001104] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography-based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.
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Affiliation(s)
| | | | | | | | | | | | - Charles Herzog
- Hennepin Healthcare/University of Minnesota, Minneapolis, MN
| | - Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
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Cardiac Imaging and Management of Cardiac Disease in Asymptomatic Renal Transplant Candidates: A Current Update. Diagnostics (Basel) 2022; 12:diagnostics12102332. [PMID: 36292020 PMCID: PMC9600087 DOI: 10.3390/diagnostics12102332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/06/2022] [Accepted: 09/19/2022] [Indexed: 11/30/2022] Open
Abstract
Given the high cardiovascular risk accompanying end-stage kidney disease, it would be of paramount importance for the clinical nephrologist to know which screening method(s) identify high-risk patients and whether screening asymptomatic transplant candidates effectively reduces cardiovascular risk in the perioperative setting as well as in the longer term. Within this review, key studies concerning the above questions are reported and critically analyzed. The lack of unified screening criteria and of a prognostically sufficient screening cardiovascular effect for renal transplant candidates sets the foundation for a personalized patient approach in the near future and highlights the need for well-designed studies to produce robust evidence which will address the above questions.
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Steinmetz T, Perl L, Zvi BR, Atamna M, Kornowski R, Shiyovich A, Hamdan A, Nesher E, Rahamimov R, Gal TB, Skalsky K. The prognostic value of pre-operative coronary evaluation in kidney transplanted patients. Front Cardiovasc Med 2022; 9:974158. [PMID: 35990935 PMCID: PMC9389011 DOI: 10.3389/fcvm.2022.974158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/11/2022] [Indexed: 11/25/2022] Open
Abstract
Aims Non-invasive coronary assessment using single-photon emission computerized tomography (SPECT) testing for potential cardiac ischemia is an essential part of the evaluation of kidney transplant candidates. We aimed to examine the prognostic value of preoperative SPECT test results in kidney transplanted patients. Methods and results We retrospectively analyzed the pre-surgical nuclear SPECT test results in a registry of kidney transplanted patients. Follow-up at 1 month and 1 year recorded major adverse cardiac events (MACE) including non-fatal myocardial infarction, all-cause mortality and hospitalization due to cardiovascular disease following the renal transplantation. Of 577 patients available for analysis, 408 (70.9%) patients underwent nuclear SPECT test pre-transplant and 83 (20.3%) had abnormal results with either evidence of ischemia or infarct. A significantly higher incidence of post-operative MACE at 1 month was evident among patients with abnormal SPECT test compared to patients with no evidence of ischemia (10.8 vs. 4.3% respectively; P = 0.019). Differences were mostly derived from significantly increased rates of myocardial infarction events (8.4 vs. 1.8%; P = 0.002). Yet, MACE rate was not statistically different at 1 year (20.5 vs. 13.1%; P = 0.88). Importantly, the prognostic impact of an abnormal SPECT was significantly attenuated for all outcomes following multivariable adjusting for conventional cardiovascular risk factors and coronary revascularization. Conclusion Pre-surgical cardiac risk assessment of kidney transplant candidates with nuclear SPECT test was found to be predictive of post-operative MACE, yet apparently, its prognostic value was significantly attenuated when adjusted for cardiac risk factors.
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Affiliation(s)
- Tali Steinmetz
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leor Perl
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Benaya Rozen Zvi
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mohamad Atamna
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arthur Shiyovich
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Ashraf Hamdan
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Eviatar Nesher
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Transplantation, Rabin Medical Center, Petach-Tikva, Israel
| | - Ruth Rahamimov
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tuvia Ben Gal
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Keren Skalsky
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
- *Correspondence: Keren Skalsky
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9
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Warrens H, Banerjee D, Herzog CA. Cardiovascular Complications of Chronic Kidney Disease: An Introduction. Eur Cardiol 2022; 17:e13. [PMID: 35620357 PMCID: PMC9127633 DOI: 10.15420/ecr.2021.54] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hilary Warrens
- St George’s University of London, St George’s NHS Foundation Trust, London, UK
| | - Debasish Banerjee
- St George’s University of London, St George’s NHS Foundation Trust, London, UK
| | - Charles A Herzog
- Division of Cardiology, Department of Internal Medicine, Hennepin Healthcare, Minneapolis, MN, US; Department of Medicine, University of Minnesota, Minneapolis, MN, US
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10
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Nakano S, Kohsaka S, Chikamori T, Fukushima K, Kobayashi Y, Kozuma K, Manabe S, Matsuo H, Nakamura M, Ohno T, Sawano M, Toda K, Ueda Y, Yokoi H, Gatate Y, Kasai T, Kawase Y, Matsumoto N, Mori H, Nakazato R, Niimi N, Saito Y, Shintani A, Watanabe I, Watanabe Y, Ikari Y, Jinzaki M, Kosuge M, Nakajima K, Kimura T. JCS 2022 Guideline Focused Update on Diagnosis and Treatment in Patients With Stable Coronary Artery Disease. Circ J 2022; 86:882-915. [DOI: 10.1253/circj.cj-21-1041] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Shintaro Nakano
- Cardiology, Saitama Medical University International Medical Center
| | | | | | - Kenji Fukushima
- Department of Radiology and Nuclear Medicine, Fukushima Medical University
| | | | - Ken Kozuma
- Cardiology, Teikyo University School of Medicine
| | - Susumu Manabe
- Cardiac Surgery, International University of Health and Welfare Mita Hospital
| | | | - Masato Nakamura
- Cardiovascular Medicine, Toho University Ohashi Medical Center
| | | | | | - Koichi Toda
- Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Yasunori Ueda
- Cardiovascular Division, National Hospital Organization Osaka National Hospital
| | - Hiroyoshi Yokoi
- Cardiovascular Center, International University of Health and Welfare Fukuoka Sanno Hospital
| | - Yodo Gatate
- Cardiology, Self-Defense Forces Central Hospital
| | | | | | | | - Hitoshi Mori
- Cardiology, Saitama Medical University International Medical Center
| | | | | | - Yuichi Saito
- Cardiovascular Medicine, Chiba University School of Medicine
| | - Ayumi Shintani
- Medical Statistics, Osaka City University Graduate School of Medicine
| | - Ippei Watanabe
- Cardiovascular Medicine, Toho University School of Medicine
| | | | - Yuji Ikari
- Cardiology, Tokai University School of Medicine
| | | | | | - Kenichi Nakajima
- Functional Imaging and Artificial Intelligence, Kanazawa University
| | - Takeshi Kimura
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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11
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Skalsky K, Shiyovich A, Steinmetz T, Kornowski R. Chronic Renal Failure and Cardiovascular Disease: A Comprehensive Appraisal. J Clin Med 2022; 11:1335. [PMID: 35268426 PMCID: PMC8911484 DOI: 10.3390/jcm11051335] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023] Open
Abstract
Coronary artery disease is highly prevalent in patients with chronic kidney disease. The concomitant renal disease often poses a major challenge in decision making as symptoms, cardiac biomarkers and noninvasive studies for evaluation of myocardial ischemia have different sensitivity and specificity thresholds in this specific population. Moreover, the effectiveness and safety of intervention and medical treatment in those patients is of great doubt as most clinical studies exclude patients with advance CKD. In the present paper, we discuss and review the literature in the diagnosis, treatment and prevention of CAD in the acute and chronic setting, in patients with CKD.
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Affiliation(s)
- Keren Skalsky
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel; (A.S.); (R.K.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Arthur Shiyovich
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel; (A.S.); (R.K.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Tali Steinmetz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
- Department of Nephrology, Rabin Medical Center, Petah Tikva 4941492, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel; (A.S.); (R.K.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
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12
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McCallum W, Sarnak MJ. Screening for Cardiovascular Disease in CKD: COMMENTARY. KIDNEY360 2022; 3:1839-1841. [PMID: 36515412 PMCID: PMC9717635 DOI: 10.34067/kid.0000742022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 02/28/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Wendy McCallum
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Mark J. Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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13
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Guía de unidades de hemodiálisis 2020. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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14
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Ferro CJ, Berry M, Moody WE, George S, Sharif A, Townend JN. Screening for occult coronary artery disease in potential kidney transplant recipients: time for reappraisal? Clin Kidney J 2021; 14:2472-2482. [PMID: 34950460 PMCID: PMC8690093 DOI: 10.1093/ckj/sfab103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/03/2021] [Indexed: 11/14/2022] Open
Abstract
Screening for occult coronary artery disease in potential kidney transplant recipients has become entrenched in current medical practice as the standard of care and is supported by national and international clinical guidelines. However, there is increasing and robust evidence that such an approach is out-dated, scientifically and conceptually flawed, ineffective, potentially directly harmful, discriminates against ethnic minorities and patients from more deprived socioeconomic backgrounds, and unfairly denies many patients access to potentially lifesaving and life-enhancing transplantation. Herein we review the available evidence in the light of recently published randomized controlled trials and major observational studies. We propose ways of moving the field forward to the overall benefit of patients with advanced kidney disease.
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Affiliation(s)
- Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Miriam Berry
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - William E Moody
- Department of Cardiology, University Hospitals Birmingham, Birmingham, UK
| | - Sudhakar George
- Department of Cardiology, University Hospitals Birmingham, Birmingham, UK
| | - Adnan Sharif
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jonathan N Townend
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, University Hospitals Birmingham, Birmingham, UK
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15
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Leidet die Niere, leidet das Herz. MMW Fortschr Med 2021; 163:12-17. [PMID: 34240353 DOI: 10.1007/s15006-021-0136-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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16
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Kohsaka S, Fukushima K, Watanabe I, Manabe S, Niimi N, Gatate Y, Sawano M, Nakano S. Contemporary Management of Stable Coronary Artery Disease - Implications of the ISCHEMIA Trial. Circ J 2021; 85:1919-1927. [PMID: 34148929 DOI: 10.1253/circj.cj-21-0345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Coronary artery disease (CAD) remains a leading cause of mortality and morbidity in developed countries. Although urgent revascularization is the cornerstone of management of acute coronary syndrome (ACS), for patients with stable CAD recent large-scale clinical trials indicate that a mechanical 'fix' of a narrowed artery is not obviously beneficial; ACS and stable CAD are increasingly recognized as different clinical entities. We review the perspectives on (1) modifying the diagnostic pathway of stable CAD with the incorporation of modern estimates of pretest probability, (2) non-imaging evaluations based on their availability, (3) the optimal timing of invasive coronary angiography and revascularization, and (4) the implementation of medical therapy during the work-up.
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Affiliation(s)
- Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Kenji Fukushima
- Department of Nuclear Medicine, Saitama Medical University International Medical Center
| | - Ippei Watanabe
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine
| | - Susumu Manabe
- Department of Cardiac Surgery, University of International Health and Welfare, Narita Hospital
| | - Nozomi Niimi
- Department of Cardiology, Keio University School of Medicine
| | - Yodo Gatate
- Department of Cardiology, Saitama Medical University International Medical Center
| | - Mitsuaki Sawano
- Department of Cardiology, Tokyo Dental College, Ichikawa General Hospital
| | - Shintaro Nakano
- Department of Cardiology, Saitama Medical University International Medical Center
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17
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Kotta PA, Elango M, Papalois V. Preoperative Cardiovascular Assessment of the Renal Transplant Recipient: A Narrative Review. J Clin Med 2021; 10:2525. [PMID: 34200235 PMCID: PMC8201125 DOI: 10.3390/jcm10112525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 12/23/2022] Open
Abstract
Patients with end-stage kidney disease (ESKD) have a high prevalence of cardiovascular disease; it is the leading cause of death in these patients and the optimisation of their cardiovascular health may improve their post-transplant outcomes. Patients awaiting renal transplant often spend significant amounts of time on the waiting list allowing for the assessment and optimisation of their cardiovascular system. Coronary artery disease (CAD) is commonly seen in these patients and we explore the possible functional and anatomical investigations that can help assess and manage CAD in renal transplant candidates. We also discuss other aspects of cardiovascular assessment and management including arrhythmias, impaired ventricular function, valvular disease, lifestyle and pulmonary arterial hypertension. We hope that this review can form a basis for centres hoping to implement an enhanced recovery after surgery (ERAS) protocol for renal transplantation.
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Affiliation(s)
| | - Madhivanan Elango
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
| | - Vassilios Papalois
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
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18
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Karimi Galougahi K, Chadban S, Mehran R, Bangalore S, Chertow GM, Ali ZA. Invasive Management of Coronary Artery Disease in Advanced Renal Disease. Kidney Int Rep 2021; 6:1513-1524. [PMID: 34169192 PMCID: PMC8207307 DOI: 10.1016/j.ekir.2021.02.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/11/2021] [Accepted: 02/22/2021] [Indexed: 12/19/2022] Open
Abstract
Coronary artery disease (CAD) is highly prevalent in chronic kidney disease (CKD). CKD modifies the effects of traditional risk factors on atherosclerosis, with CKD-specific mechanisms, such as inflammation and altered mineral metabolism, playing a dominant pathophysiological role as kidney function declines. Traditional risk models and cardiovascular screening tests perform relatively poorly in the CKD population, and medical treatments including lipid-lowering therapies have reduced efficacy. Clinical presentation of cardiac ischemia in CKD is atypical, whereas invasive therapies are associated with higher rates of complications than in with patients with normal or near normal kidney function. The main focus of the present review is on the invasive approach to management of CAD in late-stage CKD, with an in-depth discussion of the findings of the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA)-CKD trial, and their implications for therapeutic approach and future research in this area. We also briefly discuss the existing evidence in the epidemiology, pathogenesis, diagnosis, and medical management of CAD in late-stage CKD, end-stage kidney disease (ESKD), and kidney transplant recipients. We enumerate the evidence gap left by the frequent exclusion of patients with CKD from randomized controlled trials and highlight the priority areas for future research in the CKD population.
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Affiliation(s)
- Keyvan Karimi Galougahi
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Heart Research Institute, Sydney, Australia
| | - Steven Chadban
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Nephrology, Royal Prince Alfred Hospital, Sydney, Australia
- Kidney Node, Charles Perkins Centre, The University of Sydney, Australia
| | - Roxana Mehran
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sripal Bangalore
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University, Stanford, California, USA
| | - Ziad A. Ali
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
- Center for Interventional Vascular Therapy, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
- The Heart Center, St. Francis Hospital, Roslyn, New York, USA
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19
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Fathala A, Alqattan M, Alsalloum R. The diagnostic accuracy of stress myocardial perfusion scintigraphy in patients with end-stage renal disease. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2021; 11:246-252. [PMID: 34084660 PMCID: PMC8166590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/19/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE This study examined the diagnostic accuracy of myocardial perfusion scintigraphy (MPS) in end-stage renal disease (ESRD) patients and the incidence and clinical and biochemical predictors of myocardial perfusion abnormalities. METHODS We evaluated 500 asymptomatic ESRD patients on hemodialysis referred for MPS for cardiac risk stratification before renal transplant surgery. Patients with abnormal MPS and an additional few patients without abnormal MPS underwent invasive coronary angiography (ICA). RESULTS Sixty-nine patients (13%) showed abnormal MPS (reversible or fixed defect). The majority of patients had cardiovascular risk factors. There were statistically significant differences in age, male gender, hypertension, diabetes, hypercholesterolemia, and left ventricular ejection fraction (LVEF) (P < 0.05 for each) between patients with normal and abnormal MPS. Multivariate regression analysis showed that age (≥ 62 years) and low LVEF (≤ 47%) were independent predictors for abnormal MPS. ICA was performed in 112 subjects; the sensitivity, specificity, positive predictive value, and negative predictive value of MPA to detect CAD is 72%, 70%, 79%, and 61%, respectively. CONCLUSIONS In ESRD, the incidence of myocardial perfusion defects is 13%. In addition to other traditional CAD risk factors, such as diabetes and hypertension, age, and LVEF are the strongest predictors of MPS abnormalities. Initial risk stratification can be cost-effective for identifying high-risk patients who will benefit from more imaging with CAD risk factors and LVEF. In ESRD patients, MPS diagnostic performance is relatively poor. To further evaluate the utility of MPS in diagnosis and risk stratification in ESRD, more data is therefore required.
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20
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Chan K, Moe SM, Saran R, Libby P. The cardiovascular-dialysis nexus: the transition to dialysis is a treacherous time for the heart. Eur Heart J 2021; 42:1244-1253. [PMID: 33458768 PMCID: PMC8014523 DOI: 10.1093/eurheartj/ehaa1049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 08/13/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) patients require dialysis to manage the progressive complications of uraemia. Yet, many physicians and patients do not recognize that dialysis initiation, although often necessary, subjects patients to substantial risk for cardiovascular (CV) death. While most recognize CV mortality risk approximately doubles with CKD the new data presented here show that this risk spikes to >20 times higher than the US population average at the initiation of chronic renal replacement therapy, and this elevated CV risk continues through the first 4 months of dialysis. Moreover, this peak reflects how dialysis itself changes the pathophysiology of CV disease and transforms its presentation, progression, and prognosis. This article reviews how dialysis initiation modifies the interpretation of circulating biomarkers, alters the accuracy of CV imaging, and worsens prognosis. We advocate a multidisciplinary approach and outline the issues practitioners should consider to optimize CV care for this unique and vulnerable population during a perilous passage.
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Affiliation(s)
- Kevin Chan
- National Institute of Diabetes and Digestive and Kidney Disease, Division of Kidney, Urology, and Hematology, 6707 Democracy Blvd, Bethesda, MD 20892-5458, USA
| | - Sharon M Moe
- Division of Nephrology, Indiana University School of Medicine, 950 W. Walnut Street R2-202, Indianapolis, IN 46202, USA
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr # 31, Ann Arbor, MI 48109, USA
| | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 77 Ave. Louis Pasteur, NRB-741-G, Boston, MA 02115, USA
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21
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Schlieper G. Cardiovascular evaluation in advanced chronic kidney disease. Herz 2021; 46:212-216. [PMID: 33651163 DOI: 10.1007/s00059-021-05028-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2021] [Indexed: 11/28/2022]
Abstract
Patients with chronic kidney disease (CKD) display an increased cardiovascular comorbidity, which is often underdiagnosed. Thus, effective cardiovascular diagnostic testing is of particular importance for this group of patients. Data from prospective randomized trials with cardiovascular diagnostic testing in CKD patients and improved outcome are limited. Diagnostic stress testing for CKD patients requires special consideration. Guidelines recommend cardiovascular diagnostic testing for patients undergoing an evaluation before transplantation.
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Affiliation(s)
- Georg Schlieper
- Center for Nephrology, Hypertension, and Metabolic Diseases, Heidering 31, 30625, Hannover, Germany.
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22
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Treatment rationale for coronary heart disease in advanced CKD. Herz 2021; 46:221-227. [PMID: 33566140 DOI: 10.1007/s00059-021-05025-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
Chronic kidney disease (CKD) is accompanied by coronary artery disease (CAD) in most patients. In this article we describe differences in the pathogenesis, diagnosis, and treatment of CAD compared with patients without kidney impairment. The histological phenotype as well as the clinical presentation of acute and chronic coronary syndromes differ from those of patients with normal kidney function. The risk of cardiovascular events including death is strikingly increased with higher stages of CKD. Traditional but even more nontraditional cardiovascular risk factors are contributing to this increase. Screening and diagnostic procedures show limited sensitivity and specificity. Lifestyle modification is important for reducing the progression of both CKD and CAD. A special emphasis should be placed on physical exercising. Equally important is a strict antihypertensive therapy due to the very high incidences of hypertension in CKD patients. Blockade of the renin-angiotensin-system is imperative providing that adverse effects can be managed. Target blood pressure should be at 130 mm Hg systolic. Antiglycemic treatment should be implemented with metformin and SGLT2-inhibitors as first-line therapy, and glomerular filtration rate thresholds must be respected for both drugs. The risk of hypoglycemia is increased with worsening kidney function. Statins are indicated for up to stage 5 CKD. When a revascularization procedure is indicated (percutaneous intervention or bypass grafting), higher rates or peri-interventional morbidity and mortality must be anticipated. Taken together, the available literature on patients with CKD and CAD is clearly restricted compared with that on CAD patients with preserved kidney function. Mechanisms of arteriosclerosis and atheromatosis in CKD deserve more attention in the future. One major innovation in the field is SGLT2-inhibitor treatment with its concordant advantages for kidney and cardiac protection.
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23
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de Cos Gomez M, Benito Hernandez A, Garcia Unzueta MT, Mazon Ruiz J, Lopez del Moral Cuesta C, Perez Canga JL, San Segundo Arribas D, Valero San Cecilio R, Ruiz San Millan JC, Rodrigo Calabia E. Growth Differentiation Factor 15: A Biomarker with High Clinical Potential in the Evaluation of Kidney Transplant Candidates. J Clin Med 2020; 9:E4112. [PMID: 33419237 PMCID: PMC7766056 DOI: 10.3390/jcm9124112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/13/2020] [Accepted: 12/14/2020] [Indexed: 12/20/2022] Open
Abstract
Kidney transplantation implies a significant improvement in patient survival. Nevertheless, early mortality after transplant remains high. Growth differentiation factor 15 (GDF-15) is a novel biomarker under study as a mortality predictor in multiple scenarios. The aim of this study is to assess the utility of GDF-15 to predict survival in kidney transplant candidates. For this purpose, 395 kidney transplant recipients with pretransplant stored serum samples were included. The median GDF-15 was 5331.3 (50.49-16242.3) pg/mL. After a mean of 90.6 ± 41.5 months of follow-up, 82 (20.8%) patients died. Patients with higher GDF-15 levels (high risk tertile) had a doubled risk of mortality after adjustment by clinical characteristics (p = 0.009). After adjustment by EPTS (Estimated Post Transplant Survival score) the association remained significant for medium hazards ratios (HR) 3.24 95%CI (1.2-8.8), p = 0.021 and high risk tertiles HR 4.3 95%CI (1.65-11.54), p = 0.003. GDF-15 improved the prognostic accuracy of EPTS at 1-year (ΔAUC = 0.09, p = 0.039) and 3-year mortality (ΔAUC = 0.11, p = 0.036). Our study suggests an independent association between higher GDF-15 levels and mortality after kidney transplant, adding accuracy to the EPTS score, an established risk prediction model currently used in kidney transplant candidates.
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Affiliation(s)
- Marina de Cos Gomez
- Nephrology Department, Hospital Universitario Marques de Valdecilla, Avenida Valdecilla n 5, 39724 Santander, Spain; (A.B.H.); (J.M.R.); (C.L.d.M.C.); (J.L.P.C.); (R.V.S.C.); (J.C.R.S.M.); (E.R.C.)
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain; (M.T.G.U.); (D.S.S.A.)
| | - Adalberto Benito Hernandez
- Nephrology Department, Hospital Universitario Marques de Valdecilla, Avenida Valdecilla n 5, 39724 Santander, Spain; (A.B.H.); (J.M.R.); (C.L.d.M.C.); (J.L.P.C.); (R.V.S.C.); (J.C.R.S.M.); (E.R.C.)
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain; (M.T.G.U.); (D.S.S.A.)
| | - Maria Teresa Garcia Unzueta
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain; (M.T.G.U.); (D.S.S.A.)
- Clinical Analysis Department, Hospital Universitario Marques de Valdecilla, Avenida Valdecilla n 5, 39724 Santander, Spain
| | - Jaime Mazon Ruiz
- Nephrology Department, Hospital Universitario Marques de Valdecilla, Avenida Valdecilla n 5, 39724 Santander, Spain; (A.B.H.); (J.M.R.); (C.L.d.M.C.); (J.L.P.C.); (R.V.S.C.); (J.C.R.S.M.); (E.R.C.)
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain; (M.T.G.U.); (D.S.S.A.)
| | - Covadonga Lopez del Moral Cuesta
- Nephrology Department, Hospital Universitario Marques de Valdecilla, Avenida Valdecilla n 5, 39724 Santander, Spain; (A.B.H.); (J.M.R.); (C.L.d.M.C.); (J.L.P.C.); (R.V.S.C.); (J.C.R.S.M.); (E.R.C.)
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain; (M.T.G.U.); (D.S.S.A.)
| | - Jose Luis Perez Canga
- Nephrology Department, Hospital Universitario Marques de Valdecilla, Avenida Valdecilla n 5, 39724 Santander, Spain; (A.B.H.); (J.M.R.); (C.L.d.M.C.); (J.L.P.C.); (R.V.S.C.); (J.C.R.S.M.); (E.R.C.)
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain; (M.T.G.U.); (D.S.S.A.)
| | - David San Segundo Arribas
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain; (M.T.G.U.); (D.S.S.A.)
- Clinical Immunology Department, Hospital Universitario Marques de Valdecilla, Avenida Valdecilla n 5, 39724 Santander, Spain
| | - Rosalia Valero San Cecilio
- Nephrology Department, Hospital Universitario Marques de Valdecilla, Avenida Valdecilla n 5, 39724 Santander, Spain; (A.B.H.); (J.M.R.); (C.L.d.M.C.); (J.L.P.C.); (R.V.S.C.); (J.C.R.S.M.); (E.R.C.)
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain; (M.T.G.U.); (D.S.S.A.)
| | - Juan Carlos Ruiz San Millan
- Nephrology Department, Hospital Universitario Marques de Valdecilla, Avenida Valdecilla n 5, 39724 Santander, Spain; (A.B.H.); (J.M.R.); (C.L.d.M.C.); (J.L.P.C.); (R.V.S.C.); (J.C.R.S.M.); (E.R.C.)
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain; (M.T.G.U.); (D.S.S.A.)
| | - Emilio Rodrigo Calabia
- Nephrology Department, Hospital Universitario Marques de Valdecilla, Avenida Valdecilla n 5, 39724 Santander, Spain; (A.B.H.); (J.M.R.); (C.L.d.M.C.); (J.L.P.C.); (R.V.S.C.); (J.C.R.S.M.); (E.R.C.)
- Valdecilla Biomedical Research Institute (IDIVAL), Cardenal Herrera Oria S/N, 39011 Santander, Spain; (M.T.G.U.); (D.S.S.A.)
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Cheng XS, Mohanty S, Turner V, Mastrodicasa D, Winther S, Fleischmann D, Tan JC, Fearon WF. Coronary Computed Tomography Angiography in Diagnosing Obstructive Coronary Artery Disease in Patients with Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Cardiorenal Med 2020; 11:44-51. [PMID: 33321489 DOI: 10.1159/000510402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/17/2020] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Coronary computed tomography angiography (CCTA) is emerging as an important noninvasive testing modality for coronary angiography. The performance characteristic of CCTA in patients with advanced kidney disease is unknown. METHODS We performed a systematic review and meta-analysis of studies specifically investigating the sensitivity and specificity of CCTA compared to coronary angiogram as a reference standard in patients with advanced kidney disease, defined as dialysis dependence or nearing kidney transplantation. Two independent investigators assessed studies for inclusion/exclusion, quality, and characteristics, while a third investigator adjudicated. RESULTS We identified 4 studies including a total of 217 patients, of whom 159 were dialysis dependent. Three of the 4 studies had a high risk of bias in patient selection and study flow, while 1 study rated low in all areas of bias. The studies were heterogeneous in their patient selection and CCTA protocol but consistent in their definition of obstructive coronary artery disease. The pooled sensitivity and specificity for CCTA were 0.96 (0.87-0.99) and 0.66 (0.57-0.74), respectively. When we restricted the analysis to dialysis-dependent patients, the pooled sensitivity and specificity for CCTA were 0.99 (0.74-1.00) and 0.67 (0.49-0.82), respectively. CONCLUSIONS Based on limited data, CCTA appears to have comparable sensitivity but lower specificity relative to the non-kidney disease population.
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Affiliation(s)
- Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA,
| | - Suman Mohanty
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Valery Turner
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Domenico Mastrodicasa
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Simon Winther
- Department of Cardiology, Regional Hospital Unit West, Herning, Denmark
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jane C Tan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - William F Fearon
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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Abstract
Patients with chronic kidney disease (CKD) are at increased risk for kidney failure, cardiovascular disease (CVD), and death. In fact, the likelihood of dying from CVD is markedly higher than that for reaching end-stage renal disease. Evidence-based management of comorbidities such as CVD remains challenging in patients with advanced CKD, as they were usually excluded from randomized controlled trials. This review focuses on the epidemiology, risk factors, and clinical manifestations of CVD in patients with advanced CKD. Specific topics of interest include diagnostic and therapeutic challenges of heart failure, coronary artery disease, and atrial fibrillation.
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Affiliation(s)
- Turgay Saritas
- Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Jürgen Floege
- Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
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Wallar LE, De Prophetis E, Rosella LC. Socioeconomic inequalities in hospitalizations for chronic ambulatory care sensitive conditions: a systematic review of peer-reviewed literature, 1990-2018. Int J Equity Health 2020; 19:60. [PMID: 32366253 PMCID: PMC7197160 DOI: 10.1186/s12939-020-01160-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/09/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Hospitalizations for chronic ambulatory care sensitive conditions are an important indicator of health system equity and performance. Chronic ambulatory care sensitive conditions refer to chronic diseases that can be managed in primary care settings, including angina, asthma, and diabetes, with hospitalizations for these conditions considered potentially avoidable with adequate primary care interventions. Socioeconomic inequities in the risk of hospitalization have been observed in several health systems globally. While there are multiple studies examining the association between socioeconomic status and hospitalizations for chronic ambulatory care sensitive conditions, these studies have not been systematically reviewed. The objective of this study is to systematically identify and describe socioeconomic inequalities in hospitalizations for chronic ambulatory care sensitive conditions amongst adult populations in economically developed countries reported in high-quality observational studies published in the peer-reviewed literature. METHODS Peer-reviewed literature was searched in six health and social science databases: MEDLINE, EMBASE, PsycInfo, CINAHL, ASSIA, and IBSS using search terms for hospitalization, socioeconomic status, and chronic ambulatory care sensitive conditions. Study titles and abstracts were first screened followed by full-text review according to the following eligibility criteria: 1) Study outcome is hospitalization for selected chronic ambulatory care sensitive conditions; 2) Primary exposure is individual- or area-level socioeconomic status; 3) Study population has a mean age ± 1 SD < 75 years of age; 4) Study setting is economically developed countries; and 5) Study type is observational. Relevant data was then extracted, and studies were critically appraised using appropriate tools from The Joanna Briggs Institute. Results were narratively synthesized according to socioeconomic constructs and type of adjustment (minimally versus fully adjusted). RESULTS Of the 15,857 unique peer-reviewed studies identified, 31 studies met the eligibility criteria and were of sufficient quality for inclusion. Socioeconomic constructs and hospitalization outcomes varied across studies. However, despite this heterogeneity, a robust and consistent association between lower levels of socioeconomic status and higher risk of hospitalizations for chronic ambulatory care sensitive conditions was observed. CONCLUSIONS This systematic review is the first to comprehensively identify and analyze literature on the relationship between SES and hospitalizations for chronic ambulatory care sensitive conditions, considering both aggregate and condition-specific outcomes that are common to several international health systems. The evidence consistently demonstrates that lower socioeconomic status is a risk factor for hospitalization across global settings. Effective health and social interventions are needed to reduce these inequities and ensure fair and adequate care across socioeconomic groups. TRIAL REGISTRATION PROSPERO CRD42018088727.
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Affiliation(s)
- Lauren E Wallar
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3M7, Canada
| | - Eric De Prophetis
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3M7, Canada
| | - Laura C Rosella
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3M7, Canada.
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27
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Takwoingi Y, Partlett C, Riley RD, Hyde C, Deeks JJ. Methods and reporting of systematic reviews of comparative accuracy were deficient: a methodological survey and proposed guidance. J Clin Epidemiol 2020; 121:1-14. [PMID: 31843693 PMCID: PMC7203546 DOI: 10.1016/j.jclinepi.2019.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 10/02/2019] [Accepted: 12/11/2019] [Indexed: 01/27/2023]
Abstract
OBJECTIVE The objective of this study was to examine methodological and reporting characteristics of systematic reviews and meta-analyses which compare diagnostic test accuracy (DTA) of multiple index tests, identify good practice, and develop guidance for better reporting. STUDY DESIGN AND SETTING Methodological survey of 127 comparative or multiple tests reviews published in 74 different general medical and specialist journals. We summarized methods and reporting characteristics that are likely to differ between reviews of a single test and comparative reviews. We then developed guidance to enhance reporting of test comparisons in DTA reviews. RESULTS Of 127 reviews, 16 (13%) reviews restricted study selection and test comparisons to comparative accuracy studies while the remaining 111 (87%) reviews included any study type. Fifty-three reviews (42%) statistically compared test accuracy with only 18 (34%) of these using recommended methods. Reporting of several items-in particular the role of the index tests, test comparison strategy, and limitations of indirect comparisons (i.e., comparisons involving any study type)-was deficient in many reviews. Five reviews with exemplary methods and reporting were identified. CONCLUSION Reporting quality of reviews which evaluate and compare multiple tests is poor. The guidance developed, complemented with the exemplars, can assist review authors in producing better quality comparative reviews.
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Affiliation(s)
- Yemisi Takwoingi
- Test Evaluation Research Group, University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK.
| | - Christopher Partlett
- Nottingham Clinical Trials Unit, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Richard D Riley
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Staffordshire, UK
| | - Chris Hyde
- Exeter Test Group, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Jonathan J Deeks
- Test Evaluation Research Group, University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
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28
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Bangalore S, Maron DJ, O'Brien SM, Fleg JL, Kretov EI, Briguori C, Kaul U, Reynolds HR, Mazurek T, Sidhu MS, Berger JS, Mathew RO, Bockeria O, Broderick S, Pracon R, Herzog CA, Huang Z, Stone GW, Boden WE, Newman JD, Ali ZA, Mark DB, Spertus JA, Alexander KP, Chaitman BR, Chertow GM, Hochman JS. Management of Coronary Disease in Patients with Advanced Kidney Disease. N Engl J Med 2020; 382:1608-1618. [PMID: 32227756 PMCID: PMC7274537 DOI: 10.1056/nejmoa1915925] [Citation(s) in RCA: 290] [Impact Index Per Article: 72.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P = 0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P = 0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P = 0.03). CONCLUSIONS Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA-CKD ClinicalTrials.gov number, NCT01985360.).
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Affiliation(s)
- Sripal Bangalore
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - David J Maron
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Sean M O'Brien
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Jerome L Fleg
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Evgeny I Kretov
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Carlo Briguori
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Upendra Kaul
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Harmony R Reynolds
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Tomasz Mazurek
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Mandeep S Sidhu
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Jeffrey S Berger
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Roy O Mathew
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Olga Bockeria
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Samuel Broderick
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Radoslaw Pracon
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Charles A Herzog
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Zhen Huang
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Gregg W Stone
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - William E Boden
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Jonathan D Newman
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Ziad A Ali
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Daniel B Mark
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - John A Spertus
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Karen P Alexander
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Bernard R Chaitman
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Glenn M Chertow
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Judith S Hochman
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
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Schlieper G. [Cardiovascular diagnostic testing in advanced chronic kidney disease: which tests are useful?]. Internist (Berl) 2020; 61:349-356. [PMID: 31938817 DOI: 10.1007/s00108-019-00737-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Against the background of drastically increased cardiovascular comorbidity in patients with chronic kidney disease (CKD), an effective cardiovascular diagnostic approach appears essential. However, patients with CKD are often underdiagnosed. Prospective randomized studies showing an improved outcome for cardiovascular diagnostic in patients with CKD are limited. Special attention is paid to stress diagnostics in CKD patients. Guidelines recommend cardiovascular diagnostic evaluation prior to inclusion on the transplantation waiting list.
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Affiliation(s)
- Georg Schlieper
- Zentrum für Nieren‑, Hochdruck- und Stoffwechselerkrankungen, Heidering 31, 30625, Hannover, Deutschland.
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30
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Poli FE, Gulsin GS, McCann GP, Burton JO, Graham-Brown MP. The assessment of coronary artery disease in patients with end-stage renal disease. Clin Kidney J 2019; 12:721-734. [PMID: 31583096 PMCID: PMC6768295 DOI: 10.1093/ckj/sfz088] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality among patients with end-stage renal disease (ESRD). Clustering of traditional atherosclerotic and non-traditional risk factors drive the excess rates of coronary and non-coronary CVD in patients with ESRD. Coronary artery disease (CAD) is a key disease process, present in ∼50% of the haemodialysis population ≥65 years of age. Patients with ESRD are more likely to be asymptomatic, posing a challenge to the correct identification of CAD, which is essential for appropriate risk stratification and management. Given the lack of randomized clinical trial evidence in this population, current practice is informed by observational data with a significant potential for bias. For this reason, the most appropriate approach to the investigation of CAD is the subject of considerable discussion, with practice patterns largely varying between different centres. Traditional imaging modalities are limited in their diagnostic accuracy and prognostic value for cardiac events and survival in patients with ESRD, demonstrated by the large number of adverse cardiac outcomes among patients with negative test results. This review focuses on the current understanding of CAD screening in the ESRD population, discussing the available evidence for the use of various imaging techniques to refine risk prediction, with an emphasis on their strengths and limitations.
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Affiliation(s)
- Federica E Poli
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Gaurav S Gulsin
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Matthew P Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
- John Walls Renal Unit, University Hospitals Leicester NHS Trust, Leicester, UK
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Malik D, Mittal BR, Sood A, Sharma A, Parmar M, Kaur K, Bahl A. Evaluation of left ventricular mechanical dyssynchrony with phase analysis in end-stage renal disease patients with normal gated SPECT-MPI. World J Nucl Med 2019; 18:238-243. [PMID: 31516366 PMCID: PMC6714158 DOI: 10.4103/wjnm.wjnm_49_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/04/2018] [Indexed: 02/06/2023] Open
Abstract
Phase analysis using gated single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) is a relatively new tool for the assessment of ventricular synchrony. Hypertension, diabetes, renal diseases, and dyslipidemia may affect the phase parameters though their impact is not well understood. The present study aimed to evaluate the incidence of the left ventricular mechanical dyssynchrony (LVMD) in end-stage renal disease (ESRD) patients with normal gated SPECT-MPI and QRS duration (<120 ms) on electrocardiogram. Data of 129 patients (86 males) referred for gated SPECT-MPI for their pretransplant evaluation with normal gated stress SPECT-MPI (SSS <3 and ejection fraction ≥50%) were included in the study analysis. Documented clinical history along with confounding factors such as hypertension, dyslipidemia, smoking, and alcoholism were evaluated. Left ventricle functional (end-diastolic, end-systolic, and LV myocardial volume) and phase parameters (phase standard deviation [PSD], phase bandwidth [PBW] and entropy) were calculated using the QPS-QGS program. LVMD was noted in 36 (28%) of ESRD patients with normal QRS duration and gated SPECT-MPI. The mean attenuated corrected LV myocardial volume, ejection fraction, mean PSD, and PBW values were 84.3 ± 38.1 ml, 65.3 ± 13.5%, 9.8° ± 3.9°, and 61.4° ± 24.7°, respectively. The LV myocardial volume shows statistically significant correlation with the phase parameters (r = 0.31-0.47; P < 0.001). LVMD is present in a significant number of ESRD patients, and its extent is more with increase in LV myocardial volume. It may have an additional role in risk-stratification for cardiovascular disease in ESRD patients.
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Affiliation(s)
| | | | - Ashwani Sood
- Department of Nuclear Medicine, PGIMER, Chandigarh, India
| | - Ashish Sharma
- Department of Renal Surgery, PGIMER, Chandigarh, India
| | - Madan Parmar
- Department of Nuclear Medicine, PGIMER, Chandigarh, India
| | | | - Ajay Bahl
- Department of Cardiology, PGIMER, Chandigarh, India
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Buerschaper L, Floege J, Mühlfeld A, Schlieper G. Evaluation of Electrocardiographic Parameters Predicting Cardiovascular Events in Patients with End-Stage Renal Disease before and after Transplantation. Kidney Blood Press Res 2019; 44:615-627. [PMID: 31242495 DOI: 10.1159/000500917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 05/12/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Cardiovascular (CV) mortality represents the leading cause of death in patients with end-stage renal disease (ESRD). Efficient screening is required to detect CV disease at an early stage, but the best diagnostic work-up is uncertain. The aim of this study was to identify electrocardiographic parameters in dialysis patients associated with an increased frequency of CV events. METHODS A 12-lead electrocardiogram was performed in 139 patients who were on the renal transplant waiting list and who subsequently received a kidney transplant. CV events were analyzed from the day of listing for kidney transplantation until 1 year after renal transplantation. RESULTS Multivariate Cox regression analysis showed that an elevated T:R ratio in anterior and inferior leads was independently associated with CV events (T:R ratio of anterior leads hazard ratio [HR] 1.32 [95% CI 1.09-1.59; p = 0.004] and inferior leads HR 2.15 [95% CI 1.23-3.77; p = 0.008]). In particular, a T:R ratio in inferior leads exceeding 0.6 was associated with CV events in a Kaplan-Meier analysis. CONCLUSIONS Taken together, we found an increased T:R ratio in ESRD patients to be a predictive marker for CV events.
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Affiliation(s)
- Laura Buerschaper
- Department of Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Aachen, Germany,
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Aachen, Germany
| | - Anja Mühlfeld
- Department of Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Aachen, Germany
| | - Georg Schlieper
- Department of Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Aachen, Germany.,Zentrum für Nieren-, Hochdruck- und Stoffwechselerkrankungen, Hannover, Germany
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Topel M, Shaw LJ, Xie JX. Risk stratification for renal transplantation: A role for heart rate response? J Nucl Cardiol 2019; 26:823-825. [PMID: 29086385 DOI: 10.1007/s12350-017-1111-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 10/18/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Matthew Topel
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Rd. NE, Suite 514, Atlanta, GA, 30322, USA.
| | - Leslee J Shaw
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Rd. NE, Suite 514, Atlanta, GA, 30322, USA
| | - Joe X Xie
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Rd. NE, Suite 514, Atlanta, GA, 30322, USA
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Abstract
Kidney transplantation (KT) is the most effective way to decrease the high morbidity and mortality of patients with end-stage renal disease. However, KT does not completely reverse the damage done by years of decreased kidney function and dialysis. Furthermore, new offending agents (in particular, immunosuppression) added in the post-transplant period increase the risk of complications. Cardiovascular (CV) disease, the leading cause of death in KT recipients, warrants pre-transplant screening based on risk factors. Nevertheless, the screening methods currently used have many shortcomings and a perfect screening modality does not exist. Risk factor modification in the pre- and post-transplant periods is of paramount importance to decrease the rate of CV complications post-transplant, either by lifestyle modification (for example, diet, exercise, and smoking cessation) or by pharmacological means (for example, statins, anti-hyperglycemics, and so on). Post-transplantation diabetes mellitus (PTDM) is a major contributor to mortality in this patient population. Although tacrolimus is a major contributor to PTDM development, changes in immunosuppression are limited by the higher risk of rejection with other agents. Immunosuppression has also been implicated in higher risk of malignancy; therefore, proper cancer screening is needed. Cancer immunotherapy is drastically changing the way certain types of cancer are treated in the general population; however, its use post-transplant is limited by the risk of allograft rejection. As expected, higher risk of infections is also encountered in transplant recipients. When caring for KT recipients, special attention is needed in screening methods, preventive measures, and treatment of infection with BK virus and cytomegalovirus. Hepatitis C virus infection is common in transplant candidates and in the deceased donor pool; however, newly developed direct-acting antivirals have been proven safe and effective in the pre- and post-transplant periods. The most important and recent developments on complications following KT are reviewed in this article.
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Affiliation(s)
- Abraham Cohen-Bucay
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, 14080, Mexico.,Nephrology Department, American British Cowdray Medical Center, Mexico City, 05300, Mexico
| | - Craig E Gordon
- Division of Nephrology, Tufts Medical Center, Boston, MA, 02111, USA
| | - Jean M Francis
- Renal Section, Boston University Medical Center, Boston, MA, 02118, USA
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Soldera J, Camazzola F, Rodríguez S, Brandão A. Cardiac stress testing and coronary artery disease in liver transplantation candidates: Meta-analysis. World J Hepatol 2018; 10:877-886. [PMID: 30533188 PMCID: PMC6280161 DOI: 10.4254/wjh.v10.i11.877] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/13/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the diagnostic value of dobutamine stress echocardiography (DSE) and myocardial perfusion scintigraphy (MPS) in predicting coronary artery disease (CAD) in cirrhotic patients listed for liver transplantation (LT), using invasive coronary angiography (ICA) as gold-standard. METHODS Retrieval of studies was based on Medical Subject Headings and Health Sciences Descriptors, which were combined using Boolean operators. Searches were run on the electronic databases Scopus, Web of Science, EMBASE, MEDLINE (PubMed), BIREME (Biblioteca Regional de Medicina), LILACS (Latin American and Caribbean Health Sciences Literature), Cochrane Library for Systematic Reviews and Opengray.eu. There was no language or date of publication restrictions. The reference lists of the studies retrieved were searched manually. RESULTS The search strategy retrieved 322 references for DSE and 90 for MPS. In the final analysis, 10 references for DSE and 10 for MPS were included. Pooled sensitivity was 28% and 61% for DSE and MPS and specificity was 82% and 74%, for diagnosis of CAD using ICA as gold-standard, respectively. CONCLUSION DSE and MPS do not have adequate sensitivity for determination of whether CAD is present, despite having significant specificity.
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Affiliation(s)
- Jonathan Soldera
- School of Medicine, Universidade de Caxias do Sul (UCS), Caxias do Sul 95070-560, Brazil
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil.
| | - Fábio Camazzola
- School of Medicine, Universidade de Caxias do Sul (UCS), Caxias do Sul 95070-560, Brazil
| | - Santiago Rodríguez
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
| | - Ajacio Brandão
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
- Liver Transplantation Group, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90020-090, Brazil
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Herzog CA, Natwick T, Li S, Charytan DM. Comparative Utilization and Temporal Trends in Cardiac Stress Testing in U.S. Medicare Beneficiaries With and Without Chronic Kidney Disease. JACC Cardiovasc Imaging 2018; 12:1420-1426. [PMID: 29909107 DOI: 10.1016/j.jcmg.2018.04.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/04/2018] [Accepted: 04/13/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The authors aimed to analyze temporal trends in cardiac stress testing in U.S. Medicare beneficiaries from 2008 to 2012, types of stress testing, and comparative utilization related to the presence and severity of chronic kidney disease (CKD). BACKGROUND A long-held perception depicts patients with CKD as being treated less intensively for cardiovascular disease than nonrenal patients. We wondered whether use of diagnostic testing for ischemic heart disease is affected by the presence of CKD. METHODS Using the 20% Medicare sample, we assembled yearly cohorts of Medicare beneficiaries (∼4,500,000 per year) from 2008 to 2012. Beneficiaries 66 years or older undergoing a first cardiac stress test, with no previous history of coronary revascularization and no acute coronary syndrome within 60 days, were identified, as was the type of stress test. We analyzed temporal trends and compared testing rates related to CKD stage versus no CKD. A Poisson regression model estimated the likelihood of stress testing in 2012 by CKD stage, adjusted for demographic characteristics and comorbid conditions. RESULTS Approximately 480,000 older patients (∼29,000 with CKD) underwent stress tests in 2008, progressively declining to ∼400,000 in 2012 (∼38,000 with CKD). In 2008 to 2012, 78% to 80% of all stress testing in non-CKD patients used nuclear imaging, as did 87% to 88% in CKD patients. Rates of stress testing declined progressively for non-CKD and CKD patients in 2008 to 2012: 11.5 to 9.4 per 100 patient-years and 16.8 to 13.4 per 100 patient-years, respectively. The adjusted Poisson model, with non-CKD as the reference, showed an increasing likelihood of stress testing with worsening CKD: incidence rate ratio 1.01 for stages 1 to 2 (p = NS), 1.05 for stage 3 (p < 0.0001), 1.01 for stage 4 (p = NS), 1.04 for stage 5 nondialysis (p = NS), and 1.15 for stage 5 dialysis (p < 0.0001). CONCLUSIONS Overall rates of cardiac stress testing (over three-fourths using nuclear imaging) declined in 2008 to 2012 among Medicare beneficiaries 66 years or older but were consistently higher for CKD than for non-CKD patients. The effect of screening algorithms for transplant candidates was unknown. Our data refute underutilization of cardiac stress testing in CKD patients.
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Affiliation(s)
- Charles A Herzog
- Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota.
| | - Tanya Natwick
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Shuling Li
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - David M Charytan
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts
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Yilmaz KC, Akgün AN, Ciftci O, Muderrisoglu H, Sezer S, Moray G, Haberal M. Preoperative Cardiac Risk Assessment in Renal Transplant Recipients: A Single-Center Experience. EXP CLIN TRANSPLANT 2017; 17:478-482. [PMID: 29025386 DOI: 10.6002/ect.2017.0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Cardiovascular disease is the major cause of morbidity and mortality in patients on renal replacement therapy and in kidney transplant recipients. There are no specific recommendations for preoperative cardiac risk assessment before renal transplant. The aim of our study was to analyze preoperative cardiac test frequencies, test results, patient characteristics, and relations between cardiac stress test results and severe coronary artery disease. MATERIALS AND METHODS We retrospectively examined patients who underwent renal transplant between December 2011 and December 2016 in our hospital (Ankara, Turkey). Our study group included 216 patients. All patients had preoperative echocardiography. We recorded results of exercise stress tests, myocardial perfusion scintigraphy, and coronary angiography. For all patients, preoperative complete blood cell count, creatinine, high-density lipoprotein, triglycerides, low-density lipoprotein, and red cell distribution width values were obtained and recorded. RESULTS We classified patient groups according to presence or absence of severe coronary artery disease. Fourteen of 66 patients had severe coronary artery disease. In univariate analyses, age, having a history of familial coronary artery disease, diabetes mellitus, presence of coronary artery disease, and triglyceride levels were risk factors for severe coronary artery disease. In multivariate analysis, diabetes mellitus, presence of coronary artery disease, and having a history of familial coronary artery disease were statistically significant. CONCLUSIONS Renal transplant recipients are a special patient population, and there must be specific suggestions for this population. If patients present with more than 1 risk factor, a stress test should be performed to evaluate cardiovascular risk. In some patients, especially those whose risk factors include prior cardiovascular disease or diabetes mellitus, stress tests should be skipped and patients should directly undergo coronary angiography to look for severe coronary artery disease.
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Affiliation(s)
- Kerem Can Yilmaz
- From the Cardiology Department, Baskent University Faculty of Medicine, Ankara, Turkey
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Abstract
PURPOSE OF REVIEW Patients with end-stage renal disease (ESRD) have an increased risk of cardiovascular morbidity and mortality. Cardiac risk assessment, though challenging, is critical in these high-risk patients, particularly in the pre-transplant population. In this review, we discuss the burden of coronary artery disease in the ESRD population and review the literature on the diagnostic and prognostic performance, clinical value, and future directions of single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in ESRD patients. RECENT FINDINGS Stress myocardial perfusion imaging provides incremental prognostic value to clinical data. The AHA/ACCF consensus statement on the cardiac assessment of kidney transplant candidates provides some guidance on the selection of asymptomatic patients for further non-invasive risk stratification. Additionally, the novel selective A2A receptor agonist vasodilator stress agent, regadenoson, is safe and effective in ESRD and has recently been approved by the Food and Drug Administration for use in this population. Ancillary stress MPI findings, namely heart rate response to vasodilator stress, can provide incremental risk stratification. SUMMARY While myocardial perfusion imaging is widely used as a risk assessment tool, its utilization and clinical implications in the ESRD population are controversial. Though stress SPECT-MPI has imperfect diagnostic accuracy in this specific patient population, it is still a valuable non-invasive modality in cardiovascular risk assessment.
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39
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Halawa A. Evaluation of the Cardiovascular Prior to Transplantation; An Endless Debate. ACTA ACUST UNITED AC 2017. [DOI: 10.15406/unoaj.2017.04.00126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Zerillo J, Kim S, Hill B, DeMaria S, Sakai T. Noteworthy Literature Published in 2016 for Abdominal Organ Transplant Anesthesiologists. Semin Cardiothorac Vasc Anesth 2017; 21:70-80. [PMID: 28107792 DOI: 10.1177/1089253216688538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
More than 400 peer-reviewed publications on the topic of pancreas transplantation, more than 400 on intestine transplantation, and more than 3000 on renal transplantation were published in 2016. This review will highlight the most pertinent literature for anesthesiologists caring for patients undergoing non-liver abdominal organ transplantation. This review is the second part in an annual series to review relevant contributions in the field of abdominal organ transplantation focusing on pancreas, intestine, and renal transplantation. We explore a myriad of topics, including outcomes determined by center size, novel assessment of intestine graft function, the effect of Zika virus on the transplant population, appropriate fluid management for renal transplantation, cardiovascular risk assessment in the transplant population, and several topics pertinent to optimizing patient and graft survival.
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Affiliation(s)
- Jeron Zerillo
- 1 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sang Kim
- 1 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bryan Hill
- 1 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel DeMaria
- 1 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tetsuro Sakai
- 2 University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Shroff GR, Herzog CA. Coronary Revascularization in Patients with CKD Stage 5D: Pragmatic Considerations. J Am Soc Nephrol 2016; 27:3521-3529. [PMID: 27493258 DOI: 10.1681/asn.2016030345] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Coronary revascularization decisions for patients with CKD stage 5D present a dilemma for clinicians because of high baseline risks of mortality and future cardiovascular events. This population differs from the general population regarding characteristics of coronary plaque composition and behavior, accuracy of noninvasive testing, and response to surgical and percutaneous revascularization, such that findings from the general population cannot be automatically extrapolated. However, this high-risk population has been excluded from all randomized trials evaluating outcomes of revascularization. Observational studies have attempted to address long-term outcomes after surgical versus percutaneous revascularization strategies, but inherent selection bias may limit accuracy. Compared with percutaneous strategies, surgical revascularization seems to have long-term survival benefit on the basis of observational data but associates with substantially higher short-term mortality rates. Percutaneous revascularization with drug-eluting and bare metal stents associates with a high risk of in-stent restenosis and need for future revascularization, perhaps contributing to the higher long-term mortality hazard. Off-pump coronary bypass surgery and the newest generation of drug-eluting stent platforms offer no definitive benefits. In this review, we address the nuances, complexities, and tradeoffs that clinicians face in determining the optimal method of coronary revascularization for this high-risk population.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; and
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; and .,Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
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Zapf A, Brunner E, Konietschke F. A wild bootstrap approach for the selection of biomarkers in early diagnostic trials. BMC Med Res Methodol 2015; 15:43. [PMID: 25925052 PMCID: PMC4426186 DOI: 10.1186/s12874-015-0025-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 03/25/2015] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In early diagnostic trials, particularly in biomarker studies, the aim is often to select diagnostic tests among several methods. In case of metric, discrete, or even ordered categorical data, the area under the receiver operating characteristic (ROC) curve (denoted by AUC) is an appropriate overall accuracy measure for the selection, because the AUC is independent of cut-off points. METHODS For selection of biomarkers the individual AUC's are compared with a pre-defined threshold. To keep the overall coverage probability or the multiple type-I error rate, simultaneous confidence intervals and multiple contrast tests are considered. We propose a purely nonparametric approach for the estimation of the AUC's with the corresponding confidence intervals and statistical tests. This approach uses the correlation among the statistics to account for multiplicity. For small sample sizes, a Wild-Bootstrap approach is presented. It is shown that the corresponding intervals and tests are asymptotically exact. RESULTS Extensive simulation studies indicate that the derived Wild-Bootstrap approach keeps and exploits the nominal type-I error at best, even for high accuracies and in case of small samples sizes. The strength of the correlation, the type of covariance structure, a skewed distribution, and also a moderate imbalanced case-control ratio do not have any impact on the behavior of the approach. A real data set illustrates the application of the proposed methods. CONCLUSION We recommend the new Wild Bootstrap approach for the selection of biomarkers in early diagnostic trials, especially for high accuracies and small samples sizes.
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Affiliation(s)
- Antonia Zapf
- Department of Medical Statistics, University Medical Center Göttingen, Humboldtallee 32, Göttingen, 37073, Germany.
| | - Edgar Brunner
- Department of Medical Statistics, University Medical Center Göttingen, Humboldtallee 32, Göttingen, 37073, Germany.
| | - Frank Konietschke
- Department of Mathematical Sciences, The University of Texas at Dallas, 800 W Campbell Road, Richardson, 75080, TX, USA.
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Parikh K, Appis A, Doukky R. Cardiac imaging for the assessment of patients being evaluated for kidney or liver transplantation. J Nucl Cardiol 2015; 22:282-96. [PMID: 25294437 DOI: 10.1007/s12350-014-9997-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 09/10/2014] [Indexed: 01/13/2023]
Abstract
Cardiac risk assessment prior to kidney and liver transplantation is controversial. Given the paucity of available organs, selecting appropriate recipients with favorable short- and long-term cardiovascular risk profile is crucial. Using noninvasive cardiac imaging tools to guide cardiovascular risk assessment and management can also be challenging and controversial. In this article, we address the burden of coronary artery disease among kidney and liver transplant candidates and review the literature pertaining to the diagnostic accuracy and the prognostic value of noninvasive cardiac imaging techniques in this population.
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Affiliation(s)
- Kalindi Parikh
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
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Kottas M, Kuss O, Zapf A. A modified Wald interval for the area under the ROC curve (AUC) in diagnostic case-control studies. BMC Med Res Methodol 2014; 14:26. [PMID: 24552686 PMCID: PMC3938139 DOI: 10.1186/1471-2288-14-26] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 02/07/2014] [Indexed: 12/20/2022] Open
Abstract
Background The area under the receiver operating characteristic (ROC) curve, referred to as the AUC, is an appropriate measure for describing the overall accuracy of a diagnostic test or a biomarker in early phase trials without having to choose a threshold. There are many approaches for estimating the confidence interval for the AUC. However, all are relatively complicated to implement. Furthermore, many approaches perform poorly for large AUC values or small sample sizes. Methods The AUC is actually a probability. So we propose a modified Wald interval for a single proportion, which can be calculated on a pocket calculator. We performed a simulation study to compare this modified Wald interval (without and with continuity correction) with other intervals regarding coverage probability and statistical power. Results The main result is that the proposed modified Wald intervals maintain and exploit the type I error much better than the intervals of Agresti-Coull, Wilson, and Clopper-Pearson. The interval suggested by Bamber, the Mann-Whitney interval without transformation and also the interval of the binormal AUC are very liberal. For small sample sizes the Wald interval with continuity has a comparable coverage probability as the LT interval and higher power. For large sample sizes the results of the LT interval and of the Wald interval without continuity correction are comparable. Conclusions If individual patient data is not available, but only the estimated AUC and the total sample size, the modified Wald intervals can be recommended as confidence intervals for the AUC. For small sample sizes the continuity correction should be used.
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Affiliation(s)
| | | | - Antonia Zapf
- Institute for Biostatistics, Hannover Medical School, Carl-Neuberg-Str, 1, 30625 Hannover, Germany.
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Abstract
Candidates for abdominal transplant undergo a pretransplant evaluation to identify associated conditions that may require intervention or that may influence a patient's candidacy for transplant. Coronary artery disease is prevalent in candidates for abdominal organ transplantation. The optimal approach to identify and manage coronary artery disease in the peri-transplant period is currently unclear. In liver transplant candidates portopulmonary hypertension and hepatopulmonary syndrome should be screened for. Identification of the patient who is too sick to benefit from transplant is problematic; with no good evidence available decisions should be individualized and made after multidisciplinary discussion.
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Affiliation(s)
- James Y Findlay
- Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Karohl C, D'Marco L, Bellasi A, Raggi P. Hybrid myocardial imaging for risk stratification prior to kidney transplantation: added value of coronary calcium and epicardial adipose tissue. J Nucl Cardiol 2013; 20:1013-20. [PMID: 24026479 DOI: 10.1007/s12350-013-9761-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Accepted: 07/03/2013] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patient selection and optimal approach to risk stratification prior to kidney transplantation remain uncertain. We sought new predictors of an abnormal myocardial perfusion (MYP) stress test result. METHODS Retrospective study of 411 consecutive chronic kidney disease stages 4-5D patients awaiting kidney transplantation referred for risk stratification. PET-CT or SPECT-CT was used to assess MYP and quantify coronary artery calcium (CAC) and epicardial adipose tissue (EAT). Abnormal MYP was defined as a perfusion defect involving ≥5% of the left ventricular myocardium. RESULTS Fixed or reversible MYP defects were present in 41 patients (10%). Male sex, smoking, and history of cardiovascular disease were more prevalent; age was higher and CAC and EAT were greater in patients with MYP defects than in those with normal MYP. On multivariate logistic regression, EAT and CAC were independent predictors of abnormal MYP while diabetes mellitus showed a borderline association (P = .08). EAT added incremental diagnostic value to a model including age, CAC and diabetes mellitus [AUC 0.73 (95% CI 0.64-0.81) to 0.76 (95% CI 0.68-0.84; P = .02)]. Furthermore, the model containing EAT showed improved diagnostic discrimination. CONCLUSIONS Abnormal MYP on screening stress testing appears to be rare in patients awaiting kidney transplantation suggesting an excess of testing. EAT and CAC may help predict what patients are at higher risk of developing abnormalities of MYP under stress.
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Affiliation(s)
- Cristina Karohl
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Renal Allograft Implantation on Prosthetic Vascular Grafts: Short- and Long-term Results. World J Surg 2013; 37:1727-34. [DOI: 10.1007/s00268-013-2028-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
The burden of cardiovascular disease is high in patients with chronic kidney disease or end-stage renal disease. The presence of kidney dysfunction affects the cardiovascular system in multiple ways, including accelerated progression of atherosclerosis and valvular disease, the exacerbation of congestive heart failure, and the development of pericardial disease. This comorbidity results not only from the concordance of shared risk factors, but also from other issues specific to this population, such as systemic inflammation and vascular calcification. Furthermore, both the sensitivity and specificity of noninvasive testing modalities, and the efficacy of several pharmacotherapeutic strategies, are diminished in this population. The exclusion of patients with severe kidney disease from many clinical trials of cardiac interventions raises various therapeutic uncertainties, and kidney disease itself is likely to alter the underlying cardiovascular physiology. In this Review, we discuss aspects of the epidemiology, pathophysiology, and diagnosis of cardiovascular disease in patients with kidney disease, and propose specific, evidence-based recommendations for pharmacological and surgical treatment.
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