Coronary Computed Tomography Angiography in Diagnosing Obstructive Coronary Artery Disease in Patients with Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis

Abstract

<b><i>Introduction:</i></b> 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. <b><i>Methods:</i></b> 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. <b><i>Results:</i></b> 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. <b><i>Conclusions:</i></b> Based on limited data, CCTA appears to have comparable sensitivity but lower specificity relative to the non-kidney disease population.

Cardiac Biomarkers and Risk of Atherosclerotic Cardiovascular Disease in Patients with CKD

“…In this study, we found that NT-proBNP, hsTnT, and GDF-15 were significantly associated with non-zero CAC scores. However, due to the unique physiology of CKD, CAC scores in this population may reflect both intimal and medial calcification, and may lack specificity as a result 98,99 .…”

“…In this study, we found that NT-proBNP, hsTnT, and GDF-15 were significantly associated with non-zero CAC scores. However, due to the unique physiology of CKD, CAC scores in this population may reflect both intimal and medial calcification, and may lack specificity as a result (94,95). Further work on how best to identify patients with CKD at high risk for atherosclerotic CVD is needed as diagnoses of subclinical disease remains a challenge in this high-risk population.…”

Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association

“…45,46 The pooled analysis of 4 studies of patients with advanced kidney disease found a sensitivity of 0.96 and a specificity of 0.66 for CCTA for CHD. 47…”

“…45,46 The pooled analysis of 4 studies of patients with advanced kidney disease found a sensitivity of 0.96 and a specificity of 0.66 for CCTA for CHD. 47 A normal CACS or CCTA may offer reassurance, but an abnormal test can be more problematic. Despite the imperfect correlation with angiographically defined CAD, CACS and CCTA may still provide prognostic information.…”

Prognostic value of computed tomography derived fractional flow reserve for predicting cardiac events and mortality in kidney transplant candidates

“…12 Coronary CTA is limited by moderate specificity for obstructive CAD, often caused by arrhythmia, severe coronary calcification and overestimation of luminal diameter reduction. 13 Computed tomography derived fractional flow reserve (FFR CT ) allows for evaluation of the hemodynamic severity of a stenosis from standard CCTA images and has been validated in the general population. Furthermore, FFR CT shows improved prediction of MACE compared to luminal diameter reduction by CCTA in the general population [14][15][16][17][18][19] ; however, FFR CT has not been evaluated in larger cohorts of CKD patients and its potential as a risk stratification and prognostic tool has never been investigated in kidney transplant candidates.…”