Case 17

Published on 02/03/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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Case 17

A 53-year-old male with a history of diabetes, hypertension, hyperlipidemia, and end-stage renal disease (ESRD) presented to the hospital with chest pain and ruled-in non-ST-elevation myocardial infarction (NSTEMI). He had a renal transplant 3 years earlier, and his transplanted kidney is rejecting, with high serum urea (67 mg/dL) and creatinine levels (7 mg/dL), but he is still not on dialysis. Coronary angiography could not be done because of renal function impairment. He was treated medically and sent for rest and adenosine stress myocardial perfusion imaging (MPI) for risk stratification.

Medications: Aspirin, diltiazem, metoprolol, cyclosporine, Rapamune, calcitrol, prednisone, folic acid.

Pharmacologic stress test with 5-minute adenosine infusion is performed ^99mTc-sestamibi was injected during adenosine infusion. HR changes from 55 to 71 beats/min and BP from 202/101 to 176/86 mm Hg. He has no chest pain or ST depression.

Resting ECG shows normal sinus rhythm with left axis deviation, flat T waves in leads II, III, aVF, and V4-6, with no change on adenosine infusion.

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(Video 1b)

(Fig. 1a)

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Myocardial perfusion imaging shows a small area of perfusion abnormality involving the inferior wall, with minimal reversibility on the rest images. The inferior wall is hypokinetic and the left ventricular ejection fraction (LVEF) is mildly depressed at 45%. There is transient poststress LV dilation with transient ischemic dilation (TID) of 1.44.

Chronic kidney disease (CKD) is an independent risk factor for obstructive coronary artery disease, and patients with CKD have higher cardiovascular mortality (See Chapter 16). Another important management factor to consider in this patient is tighter BP control. The patient will need to undergo coronary angiography after he starts hemodialysis. If he receives another renal transplant, he will need catheterization prior to the surgery.

FURTHER READING

1. Cook J.R., Dillie K.S., Hakeem A., et al. Effectiveness of anemia and chronic kidney disease as predictors for presence and severity of coronary artery disease in patients undergoing stress myocardial perfusion study. Am J Cardiol. 2008;102:266-271.

2. Chonchol M., Whittle J., Desbien A., et al. Chronic kidney disease is associated with angiographic coronary artery disease. Am J Nephrol. 2008;28:354-360.

3. Rabbat C.G., Treleaven D.J., Russell J.D., et al. 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;14:431-439.

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