title: Prognostic Value of Coronary Flow Reserve in Patients with Dialysis-Dependent ESRD.
abstract: Capillary rarefaction of the coronary microcirculation is a consistent phenotype in patients with dialysis-dependent ESRD (dd-ESRD) and may help explain their excess mortality. Global coronary flow reserve (CFR) assessed by positron emission tomography (PET) is a noninvasive, quantitative marker of myocardial perfusion and ischemia that integrates the hemodynamic effects of epicardial stenosis, diffuse atherosclerosis, and microvascular dysfunction. We tested whether global CFR provides risk stratification in patients with dd-ESRD. Consecutive patients with dd-ESRD clinically referred for myocardial perfusion PET imaging were retrospectively included, excluding patients with prior renal transplantation. Per-patient CFR was calculated as the ratio of stress to rest absolute myocardial blood flow. Multivariable Cox proportional hazards models, including age, overt cardiovascular disease, and myocardial scar/ischemia burden, were used to assess the independent association of global CFR with all-cause and cardiovascular mortality. The incremental value of global CFR was assessed with relative integrated discrimination index and net reclassification improvement. In 168 patients included, median global CFR was 1.4 (interquartile range, 1.2-1.8). During follow-up (median of 3 years), 36 patients died, including 21 cardiovascular deaths. Log-transformed global CFR independently associated with all-cause mortality (hazard ratio, 0.01 per 0.5-unit increase; 95% confidence interval, <0.01 to 0.14; P<0.001) and cardiovascular mortality (hazard ratio, 0.01 per 0.5-unit increase; 95% confidence interval, <0.01 to 0.15; P=0.002). For all-cause mortality, addition of global CFR resulted in risk reclassification in 27% of patients. Thus, global CFR may provide independent and incremental risk stratification for all-cause and cardiovascular mortality in patients with dd-ESRD.
authors.affiliation: Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts; mdicarli@partners.org.
authors.forename: Nishant R
authors.initials: NR
authors.lastname: Shah
authors.affiliation: Departments of Medicine and.
authors.forename: David M
authors.initials: DM
authors.lastname: Charytan
authors.affiliation: Department of Medicine and Radiology, University of Michigan, Ann Arbor, Michigan; and.
authors.forename: Venkatesh L
authors.initials: VL
authors.lastname: Murthy
authors.affiliation: Departments of Medicine and.
authors.forename: Hicham
authors.initials: H
authors.lastname: Skali Lami
authors.affiliation: Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts;
authors.forename: Vikas
authors.initials: V
authors.lastname: Veeranna
authors.affiliation: Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts;
authors.forename: Michael K
authors.initials: MK
authors.lastname: Cheezum
authors.affiliation: Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts;
authors.forename: Viviany R
authors.initials: VR
authors.lastname: Taqueti
authors.affiliation: Department of Medicine, Gifu Prefectural General Medical Center, Gifu City, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Kato
authors.affiliation: Radiology, Brigham and Women's Hospital, Boston, Massachusetts;
authors.forename: Courtney R
authors.initials: CR
authors.lastname: Foster
authors.affiliation: Radiology, Brigham and Women's Hospital, Boston, Massachusetts;
authors.forename: Jon
authors.initials: J
authors.lastname: Hainer
authors.affiliation: Radiology, Brigham and Women's Hospital, Boston, Massachusetts;
authors.forename: Mariya
authors.initials: M
authors.lastname: Gaber
authors.affiliation: Departments of Medicine and.
authors.forename: Josh
authors.initials: J
authors.lastname: Klein
authors.affiliation: Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts;
authors.forename: Sharmila
authors.initials: S
authors.lastname: Dorbala
authors.affiliation: Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts;
authors.forename: Ron
authors.initials: R
authors.lastname: Blankstein
authors.affiliation: Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, Massachusetts;
authors.forename: Marcelo F
authors.initials: MF
authors.lastname: Di Carli
mesh_terms: D000368:Aged; D003326:Coronary Circulation; D003331:Coronary Vessels / Q000503:physiopathology*; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000503:physiopathology* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D006435:Renal Dialysis; D012189:Retrospective Studies
keywords: cardiovascular disease; mortality risk; outcomes; survival