Journal of Nuclear Cardiology

, Volume 20, Issue 6, pp 1013–1020 | Cite as

Hybrid myocardial imaging for risk stratification prior to kidney transplantation: Added value of coronary calcium and epicardial adipose tissue

  • Cristina Karohl
  • Luis D’Marco
  • Antonio Bellasi
  • Paolo Raggi
Original Article



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.


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.


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.


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.


Myocardial perfusion imaging SPECT PET/CT imaging coronary artery disease 



We thank Robert Wilson, RN for his help identifying the patients on the kidney transplant list that were included in this report.

Conflict of interest

The authors have no conflict to disclose in connection with the contents of this article.


  1. 1.
    Schindler TH, Schelbert HR, Quercioli A, Dilsizian V. Cardiac PET imaging for the detection and monitoring of coronary artery disease and microvascular health. JACC Cardiovasc Imaging 2010;3:623-40.PubMedCrossRefGoogle Scholar
  2. 2.
    Rabkin SW. Epicardial fat: Properties, function and relationship to obesity. Obes Rev 2007;8:253-61.PubMedCrossRefGoogle Scholar
  3. 3.
    Iacobellis G, Malavazos AE, Corsi MM. Epicardial fat: From the biomolecular aspects to the clinical practice. Int J Biochem Cell Biol 2011;43:1651-4.PubMedCrossRefGoogle Scholar
  4. 4.
    Guaraldi G, Scaglioni R, Zona S, Orlando G, Carli F, Ligabue G, et al. Epicardial adipose tissue is an independent marker of cardiovascular risk in HIV-infected patients. AIDS 2011;25:1199-205.PubMedCrossRefGoogle Scholar
  5. 5.
    Bachar GN, Dicker D, Kornowski R, Atar E. Epicardial adipose tissue as a predictor of coronary artery disease in asymptomatic subjects. Am J Cardiol 2012;110:534-8.PubMedCrossRefGoogle Scholar
  6. 6.
    Sarin S, Wenger C, Marwaha A, Qureshi A, Go BD, Woomert CA, et al. Clinical significance of epicardial fat measured using cardiac multislice computed tomography. Am J Cardiol 2008;102:767-71.PubMedCrossRefGoogle Scholar
  7. 7.
    Alexopoulos N, McLean DS, Janik M, Arepalli CD, Stillman AE, Raggi P. Epicardial adipose tissue and coronary artery plaque characteristics. Atherosclerosis 2010;210:150-4.PubMedCrossRefGoogle Scholar
  8. 8.
    Janik M, Hartlage G, Alexopoulos N, Mirzoyev Z, McLean DS, Arepalli CD, et al. Epicardial adipose tissue volume and coronary artery calcium to predict myocardial ischemia on positron emission tomography-computed tomography studies. J Nucl Cardiol 2010;17:841-7.PubMedCrossRefGoogle Scholar
  9. 9.
    Agatston A, Janowitz W, Hildner F, Zusmer N, Viamonte M, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 1990;15:827-32.PubMedCrossRefGoogle Scholar
  10. 10.
    Akinboboye O, Nichols K, Dim U, Wang Y, Chhabra S, Milo T. Epicardial fat: An unrecognized cause of artifact on myocardial perfusion imaging. Clin Nucl Med 2006;31:333-4.PubMedCrossRefGoogle Scholar
  11. 11.
    Gorter PM, van Lindert ASR, de Vos AM, Meijs MFL, van der Graaf Y, Doevendans PA, et al. Quantification of epicardial and peri-coronary fat using cardiac computed tomography; reproducibility and relation with obesity and metabolic syndrome in patients suspected of coronary artery disease. Atherosclerosis 2008;197:896-903.PubMedCrossRefGoogle Scholar
  12. 12.
    Pencina MJ, D’Agostino RB, Steyerberg EW. Extensions of net reclassification improvement calculations to measure usefulness of new biomarkers. Stat Med 2011;30:11-21.PubMedCrossRefGoogle Scholar
  13. 13.
    Ding J, Hsu FC, Harris TB, Liu Y, Kritchevsky SB, Szklo M, et al. The association of pericardial fat with incident coronary heart disease: The Multi-Ethnic Study of Atherosclerosis (MESA). Am J Clin Nutr 2009;90:499-504.PubMedCrossRefGoogle Scholar
  14. 14.
    Mahabadi AA, Berg MH, Lehmann N, Kälsch H, Bauer M, Kara K, et al. Association of epicardial fat with cardiovascular risk factors and incident myocardial infarction in the general population: The Heinz Nixdorf Recall Study. J Am Coll Cardiol 2013;61:1388-95.PubMedCrossRefGoogle Scholar
  15. 15.
    Djaberi R, Schuijf JD, van Werkhoven JM, Nucifora G, Jukema JW, Bax JJ. Relation of epicardial adipose tissue to coronary atherosclerosis. Am J Cardiol 2008;102:1602-7.PubMedCrossRefGoogle Scholar
  16. 16.
    Iwasaki K, Matsumoto T, Aono H, Furukawa H, Samukawa M. Relationship between epicardial fat measured by 64-multidetector computed tomography and coronary artery disease. Clin Cardiol 2011;34:166-71.PubMedCrossRefGoogle Scholar
  17. 17.
    Ueno K, Anzai T, Jinzaki M, Yamada M, Jo Y, Maekawa Y, et al. Increased epicardial fat volume quantified by 64-multidetector computed tomography is associated with coronary atherosclerosis and totally occlusive lesions. Circ J 2009;73:1927-33.PubMedCrossRefGoogle Scholar
  18. 18.
    Nakazato R, Dey D, Cheng VY, Gransar H, Slomka PJ, Hayes SW, et al. Epicardial fat volume and concurrent presence of both myocardial ischemia and obstructive coronary artery disease. Atherosclerosis 2012;221:422-6.PubMedCrossRefGoogle Scholar
  19. 19.
    Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL, et al. Cardiac disease evaluation and management among kidney and liver transplantation candidates: A scientific statement from the American Heart Association and the American College of Cardiology Foundation. J Am Coll Cardiol 2012;60:434-80.PubMedCrossRefGoogle Scholar
  20. 20.
    Wang LW, Fahim MA, Hayen A, Mitchell RL, Baines L, Lord S, et al. Cardiac testing for coronary artery disease in potential kidney transplant recipients. Cochrane Database Syst Rev 2011. doi: 10.1002/14651858.
  21. 21.
    De Lima J, Gowdak LH, de Paula F. Diagnosis and treatment of coronary artery disease in hemodialysis patients evaluated for transplant. Transplant Res 2012;1:3. doi: 10.1186/2047-1440-1-3.PubMedCrossRefGoogle Scholar
  22. 22.
    Rabbat CG, Treleaven DJ, Russel JD, Ludwin D, Cook D. Prognostic value of myocardial perfusion studies in patients with end-stage renal disease assessed for kidney or kidney-pancreas transplantation: A meta-analysis. J Am Soc Nephrol 2003;14:431-9.PubMedCrossRefGoogle Scholar
  23. 23.
    Rozanski A, Gransar H, Hayes SW, Min J, Friedman JD, Thomson LE, et al. Temporal trends in the frequency of inducible myocardial ischemia during cardiac stress testing: 1991 to 2009. J Am Coll Cardiol 2013;61:1054-65.PubMedCrossRefGoogle Scholar
  24. 24.
    Turkmen K, Kayikcioglu H, Ozbek O, Solak Y, Kayrak M, Samur C, et al. The relationship between epicardial adipose tissue and malnutrition, inflammation, atherosclerosis/calcification syndrome in ESRD patients. Clin J Am Soc Nephrol 2011;6:1920-5.PubMedCrossRefGoogle Scholar
  25. 25.
    Kerr JD, Holden RM, Morton AR, Nolan RL, Hopman WM, Pruss CM, et al. Associations of epicardial fat with coronary calcification, insulin resistance, inflammation, and fibroblast growth factor-23 in stage 3-5 chronic kidney disease. BMC Nephrol 2013;14:1471-2369.CrossRefGoogle Scholar
  26. 26.
    Matsuoka M, Iseki K, Tamashiro M, Fujimoto N, Higa N, Touma T, et al. Impact of high coronary artery calcification score (CACS) on survival in patients on chronic hemodialysis. Clin Exp Nephrol 2004;8:54-8.PubMedCrossRefGoogle Scholar
  27. 27.
    Block GA, Raggi P, Bellasi A, Kooienga L, Spiegel DM. Mortality effect of coronary calcification and phosphate binder choice in incident hemodialysis patients. Kidney Int 2007;71:438-41.PubMedCrossRefGoogle Scholar
  28. 28.
    Russo D, Corrao S, Battaglia Y, Andreucci M, Caiazza A, Carlomagno A, et al. Progression of coronary artery calcification and cardiac events in patients with chronic renal disease not receiving dialysis. Kidney Int 2011;80:112-8.PubMedCrossRefGoogle Scholar
  29. 29.
    Schenker MP, Dorbala S, Hong EC, Rybicki FJ, Hachamovitch R, Kwong RY, et al. Interrelation of coronary calcification, myocardial ischemia, and outcomes in patients with intermediate likelihood of coronary artery disease: A combined positron emission tomography/computed tomography study. Circulation 2008;117:1693-700.PubMedCrossRefGoogle Scholar
  30. 30.
    Raggi P, Berman DS. Computed tomography coronary calcium screening and myocardial perfusion imaging. J Nucl Cardiol 2005;12:96-103.PubMedCrossRefGoogle Scholar
  31. 31.
    Berman DS, Wong ND, Gransar H, Miranda-Peats R, Dahlbeck J, Hayes SW, et al. Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography. J Am Coll Cardiol 2004;44:923-30.PubMedCrossRefGoogle Scholar
  32. 32.
    Esteves FP, Khan A, Correia LC, Nye JA, Halkar RK, Schuster DM, et al. Absent coronary artery calcium excludes inducible myocardial ischemia on computed tomography/positron emission tomography. Int J Cardiol 2011;147:424-7.PubMedCrossRefGoogle Scholar
  33. 33.
    Ferramosca E, Di Felice A, Ratti C, Ligabue G, Ibrahim D, Modena MG, et al. Screening for silent ischemia with coronary artery calcium and nuclear stress testing in nondiabetic patients prior to kidney transplant. J Nephrol 2006;19:473-80.PubMedGoogle Scholar
  34. 34.
    Sharples EJ, Pereira D, Summers S, Cunningham J, Goldsmith D, Yaqoob MM. Coronary artery calcification measured with electron-beam computerized tomography correlates poorly with coronary artery angiography in dialysis patients. Am J Kidney Dis 2004;43:313-9.PubMedCrossRefGoogle Scholar
  35. 35.
    Dey D, Nakazato R, Li D, Berman DS. Epicardial and thoracic fat—Noninvasive measurement and clinical implications. Cardiovasc Diagn Ther 2012;2:85-93.Google Scholar

Copyright information

© American Society of Nuclear Cardiology 2013

Authors and Affiliations

  • Cristina Karohl
    • 1
  • Luis D’Marco
    • 2
  • Antonio Bellasi
    • 3
  • Paolo Raggi
    • 4
    • 5
  1. 1.Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do SulPorto AlegreBrazil
  2. 2.Department of NephrologyHospital Universitario Ruíz y Páez, Universidad de OrienteCiudad BolívarVenezuela
  3. 3.Department of NephrologyOspedale Sant’AnnaComoItaly
  4. 4.Mazankowski Alberta Heart InstituteUniversity of Alberta School of MedicineEdmontonCanada
  5. 5.Department of RadiologyEmory UniversityAtlantaUSA

Personalised recommendations