Exploring the elusive link between subclinical fibrosis and clinical events in end-stage renal disease: does cardiac magnetic resonance imaging hold the key?

Extensive myocardial fibrosis is known to occur in patients undergoing dialysis due to a variety of mechanisms not necessarily restricted to coronary artery disease. Fibrosis may predispose to reentry arrhythmias and long-term myocardial dysfunction, and sudden death and congestive heart failure are the most frequent causes of death in patients undergoing renal replacement therapy. Despite the high accuracy of magnetic resonance for imaging of myocardial fibrosis, its use has been restricted by the risk of inducing nephrogenic systemic sclerosis with the injection of gadolinium. The development of new sequences that allow the detection and quantifying of the severity of extracellular myocardial fibrosis offers a chance to study the pathogenesis of this condition and identify potential interventions to retard or reverse it. Whether these will lead to an improved outcome needs to be prospectively tested.