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Patients with end-stage renal disease have a high risk of cardiovascular events, and are often referred for non-invasive screening prior to kidney transplantation. Several European and North American professional organizations have issued guidelines on what tests to perform and which patients may benefit most from them. There is some discrepancy between the various guidelines and their application varies broadly across medical centers and countries. In this review, we briefly discuss the advantages and disadvantages of the non-invasive imaging methodologies that can be used to risk stratify patients prior to transplant. We conclude by offering some practical recommendations on how to approach risk stratification in this population of patients.

Atherosclerosis is an almost universal disease of human kind and involves infiltration of lipids, inflammation and calcification in the subintimal space. Coronary artery calcium (CAC) accumulates within the context of subintimal atherosclerosis and is a highly specific marker of pre-clinical disease. The prognostic significance of CAC has been elucidated during the past 20 years of research and it is now considered the best non-invasive marker to enhance prediction of adverse events in the general population as well as several disease states, such as diabetes mellitus, chronic kidney disease and HIV. However, the prognostic significance of CAC is not the same for all carriers of this marker, although it is well established that its absence is associated with an extremely low and long-lasting probability of cardiovascular events even in subjects at high risk. In this review, we discuss the current knowledge of the epidemiology and clinical significance of CAC in patients of different race, sex and age and summarize the current recommendations on its use in clinical practice.

Imaging has contributed to the successful reduction of cardiovascular morbidity and mortality in the general population and it has demonstrated excellent potential among patients with chronic kidney disease (CKD). The well-known severity of cardiovascular disease in patients suffering from CKD requires an accurate risk stratification of these patients in several clinical situations. Alterations of both structure and function of the myocardium as well as severe vasculopathy are highly prevalent in patients with advanced CKD. Hence sophisticated imaging techniques are at times necessary to make an accurate assessment of risk. Two main forms of arterial pathology develop in patients with CKD: atherosclerosis, with accumulation of inflammatory cells, lipids, fibrous tissue and calcium in the sub-intimal space of the artery, and arteriosclerosis. The latter is characterized by thickening and calcification of the muscular layer of the arterial wall and it is not necessarily associated with typical atherosclerotic changes. This review explores the indications, strengths and weaknesses of several invasive and non-invasive imaging modalities employed to evaluate myocardial and vascular disease in CKD., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

Cardiovascular disease is the first cause of morbidity and mortality for both men and women in developed countries. Tracking the progression of the atherosclerotic plaque appears to be an effective way to predict modification of risk in individual patients. Quantitative coronary angiography was initially proposed as a method of choice to assess coronary disease progression. With this methodology it was possible to demonstrate a strong association of plaque regression with reduction in adverse cardiovascular outcomes. More recently, the focus of research has turned to the development of noninvasive modalities to image the atherosclerotic plaque in its preclinical stages and to evaluate the effectiveness of preventive therapies with sequential imaging. The ease of performance of these tests enabled their use as intermediate endpoints in clinical trials to test new strategies to treat atherosclerosis. If proven successful, these imaging tools may allow a reduction in size and duration of clinical trials with a substantial cost benefit for society.

The use of noninvasive imaging techniques like electron beam and multislice computed tomography, to measure coronary artery calcium, is becoming increasingly accepted for risk stratification in both symptomatic and asymptomatic populations. The National Cholesterol Education Panel guidelines indicate that measurement of coronary calcium is an option for advanced risk assessment in appropriately selected persons. Because of the recognized high risk for cardiovascular events in patients with diabetes, they belong to the same high-risk category previously reserved for patients with known coronary heart disease. Diabetic patients might benefit from risk stratification with these noninvasive techniques. Indeed, absence of coronary calcium might indicate a low risk for events, while the presence of moderate to high calcium scores may help physicians to better gauge the intensity of medical therapy provided to their patients.

Coronary artery disease is very prevalent in western countries and it represents the most frequent cause of death for both men and women. In the United States over 7 million people suffer from this ailment and about 500,000 die each year from its complications. Often the presenting event is an acute myocardial infarction or sudden death and the cost for society both financial and in terms of human lives lost is excessive. Despite the emphasis on prevention of atherosclerosis, unheralded events continue to occur in the general population in the absence of established risk factors. Indeed, risk factors justify only 60-70% of the risk of events for an individual patient. The focus of research has therefore turned to the application of non-invasive modalities for the imaging of the atherosclerotic plaque in its pre-clinical stages. The aim is to apply this information to guide a physician in choosing the patient in need of more aggressive preventive measures. One such imaging modality, electron beam tomography, is employed to visualize the calcified component of the atherosclerotic plaque. Calcium deposition in the wall of the coronary arteries is a highly sensitive and specific marker of atherosclerotic disease. This article summarizes the extensive amount of research published during the past 15 years on the use of calcium imaging as a tool to predict events.