Feasibility and Prognostic Value of Stress Cardiovascular Magnetic Resonance in Patients With End-Stage Renal Disease.

Background: Patients with end-stage renal disease (ESRD) are at high cardiovascular risk. The safety and prognostic value of stress cardiovascular magnetic resonance (CMR) in ESRD patients remains unclear as data are lacking due to perceived contrast agent-related risk.

Objectives: The authors aimed to assess the safety and prognostic value of stress CMR in asymptomatic ESRD patients on waitlist for kidney transplantation.

Methods: This was an observational single-center cohort study of asymptomatic patients with ESRD (estimated glomerular filtration rate <30 mL/min/1.73 m or on dialysis) referred for stress CMR. Patterns of abnormal perfusion and late gadolinium enhancement were classified as typical or atypical for ischemic heart disease. Patients were followed for the occurrence of major adverse cardiovascular events (MACE) and contrast-related complications.

Results: Of 3328 ESRD patients, 845 (age 60 years [53-66], 67% men) were included with a median follow-up of 5.4 years. No major CMR-related adverse events occurred. Abnormal perfusion (12%) and presence of late gadolinium enhancement (22%) were strongly associated with the occurrence of MACE and remained independent of traditional risk factors including prior coronary disease (respectively, aHR: 4.76 [95% CI: 3.34-6.79]; aHR: 3.86 [95% CI: 2.59-5.74]; P < 0.001). Both typical and atypical ischemic heart disease patterns were independently associated with MACE (aHR: 5.68 [95% CI: 3.39-9.52] and aHR: 5.84 [95% CI: 3.82-8.91]; P < 0.001). CMR findings improved prognostic accuracy beyond American Heart Association 2012 risk criteria for ESRD patients (C-statistic improvement: 0.10).

Conclusions: In ESRD patients, stress CMR is feasible, safe, and adds significant prognostic value for MACE beyond traditional risk factors by characterizing patterns of microvascular and macrovascular disease.