The optimal method of non-invasive evaluation of ischemia in chronic kidney disease (CKD) is as elusive as the Holy Grail, and at times the choice feels almost as perilous. As with any test in medicine, there are trade-offs between sensitivity and specificity when evaluating test accuracy, i.e., striking the balance between ensuring that those with disease are not missed due to false-negative studies, while avoiding false-positive tests that could lead to unnecessary invasive diagnostic evaluation. The stakes for accuracy with non-invasive imaging are higher in the CKD population compared to the general population due to a higher pretest prevalence of obstructive coronary artery disease (CAD), higher burden of cardiovascular disease (CVD) events, and a higher risk of complications (including contrast induced acute kidney injury) from an invasive approach.

There are many small, older studies that can be grouped into two categories: (1) studies that assessed the diagnostic accuracy of dobutamine stress echo (DSE) or myocardial perfusion imaging (MPI) in predicting coronary artery disease (CAD) using invasive coronary angiography (ICA) as the reference standard, or (2) studies that assessed the accuracy of DSE or MPI in predicting clinical outcomes like all-cause mortality (ACM), cardiac death (CD), or myocardial infarction (MI). Most of these studies were small, single center, observational studies, usually involving less than 200 patients. There are several observational studies evaluating the use of DSE across the spectrum of the general CKD population, using various approaches ranging from clinical risk stratification to assessing prognostic impact. One interesting study evaluated a strategy using clinical risk scoring in conjunction with DSE for risk stratification in patients with advanced CKD, while another looked at the prognostic value of DSE for ACM in those with advanced CKD. The largest and most recent study evaluated the risk of ACM and other clinical outcomes in patients across the strata of renal disease that underwent DSE. The CKD population is susceptible to a high competing risk of all-cause mortality that exceeds the risk of death from CV causes. This fact defines this high-risk population and sets it apart from the general population with normal renal function.

Regards

Calvin Parker

Editorial Assistant

Journal of Nephrology and Urology