Background-Patients with chronic kidney disease (CKD) have worse cardiovascular outcomes than those without CKD. The prognostic utility of myocardial perfusion single-photon emission CT (MPS) in patients with varying degrees of renal dysfunction and the impact of CKD on cardiac death prediction in patients undergoing MPS have not been investigated. Methods and Results-We followed up 1652 consecutive patients who underwent stress MPS (32% exercise, 95% gated) for cardiac death for a mean of 2.15Ϯ0.8 years. MPS defects were defined with a summed stress score (normal summed stress score Ͻ4, abnormal summed stress scoreՆ4). Ischemia was defined as a summed stress score Ն4 plus a summed difference score Ն2, and scar was defined as a summed difference score Ͻ2 plus a summed stress score Ն4. Renal function was calculated with the Modified Diet in Renal Disease equation. CKD (estimated glomerular filtration rate Ͻ60 mL · min Ϫ1 · 1.73 m Ϫ2 ) was present in 36%. Cardiac death increased with worsening levels of perfusion defects across the entire spectrum of renal function. Presence of ischemia was independently predictive of cardiac death, all-cause mortality, and nonfatal myocardial infarction. Patients with normal MPS and CKD had higher unadjusted cardiac death event rates than those with no CKD and normal MPS (2.7% versus 0.8%, Pϭ0.001). Multivariate Cox proportional hazards models revealed that both perfusion defects (hazard ratio 1.90, 95% CI 1.47 to 2.46) and CKD (hazard ratio 1.96, 95% CI 1.29 to 2.95) were independent predictors of cardiac death after accounting for risk factors, left ventricular dysfunction, pharmacological stress, and symptom status. Both MPS and CKD had incremental power for cardiac death prediction over baseline risk factors and left ventricular dysfunction (global 2 207.5 versus 169.3, PϽ0.0001). Conclusions-MPS

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