Troponin is related to left ventricular mass and predicts all-cause and cardiovascular mortality in hemodialysis patients

doi:10.1053/ajkd.2002.33914

American Journal of Kidney Diseases

Volume 40, Issue 1, July 2002, Pages 68-75

https://doi.org/10.1053/ajkd.2002.33914 Get rights and content

Abstract

Cardiac troponin T (cTnT) predicts death and cardiovascular outcomes in clinically stable patients with end-stage renal disease. Because this protein is synthesized exclusively in myocardial cells, its predictive power for these outcomes may be because it reflects, besides cardiac ischemia, left ventricular (LV) mass, which is a strong predictor of cardiovascular death in this population per se. We tested the relationship between cTnT level and LV mass and the predictive power of this cardiac protein for all-cause and cardiovascular mortality in a cohort of hemodialysis patients (n = 199) without acute coronary syndrome and heart failure followed up for an average of 35 months (range, 0.8 to 52 months). cTnT was measured by means of a third-generation electrochemiluminescence immunoassay. cTnT level was related directly to interventricular septum (r = 0.36; P < 0.001) and posterior wall thickness (r = 0.40; P < 0.001), as well as LV mass (r = 0.45; P < 0.001). On multivariate analysis, after age, LV mass was the strongest independent predictor of cTnT level (β = 0.28; P < 0.001). Serum cTnT level was significantly related to all-cause and cardiovascular mortality on univariate analysis (P < 0.001). On multivariate Cox regression analysis, the adjusted risk for all-cause death was 2.39 times (95% confidence interval [CI], 1.13 to 5.06; P = 0.02) greater in patients in the third cTnT tertile than the first tertile, and a similar pattern emerged for cardiovascular mortality (hazard ratio, 2.35; 95% CI, 1.01 to 5.49; P = 0.048). In hemodialysis patients, plasma cTnT level is independently related to LV mass and predicts all-cause and cardiovascular mortality. These data support the hypothesis that this marker can be usefully applied for risk stratification in clinically stable dialysis patients. © 2002 by the National Kidney Foundation, Inc.

Section snippets

Protocol

The protocol was in conformity to the ethical guidelines of our institutions, and informed consent was obtained from each participant. All studies were performed during a nondialysis day between 8:00 am and 1:00 pm.

Study cohort

One hundred ninety-nine patients with ESRD (111 men, 88 women) on regular dialysis treatment (RDT) for at least 6 months (median duration of RDT, 44 months; interquartile range, 21 to 110 months) without a history of congestive heart failure¹⁴ and without intercurrent illnesses were

Results

Median serum cTnT level in dialysis patients was 0.071 μg/L (interquartile range, 0.041 to 0.136 μg/L). Serum cTnT concentration was less than the limit of detection (0.010 μg/L) in only 12 of 199 patients. Demographic, anthropometric, clinical, and biochemical data of the study population are listed in Table 1.

Discussion

This study shows that in clinically stable dialysis patients, serum cTnT concentration is independently linked to LV mass. Furthermore, cTnT level predicts total and cardiovascular mortality.

Cardiovascular complications represent a fundamental factor limiting survival and rehabilitation in patients with advanced renal diseases. Specific recommendations have been formulated to promote clinical research finalized at standardizing cardiovascular risk factor measurement to investigate risk factors

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Cited by (147)

Are troponin and B-type natriuretic peptides useful biomarkers for the diagnosis of systemic sclerosis heart involvement? A systematic literature review
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Systemic sclerosis (SSc) heart involvement (SHI) is a leading cause of SSc-associated mortality and once clinically overt, carries a very poor prognosis. There remain no established diagnostic criteria for SHI. This study aimed to systematically review the literature regarding the role of cardiac troponin (cTn) and B-type natriuretic peptide (BNP) or N-terminal B-type natriuretic peptide (NT-proBNP) in the diagnosis of SHI.
A comprehensive search of the MEDLINE (Ovid), EMBASE and Pubmed databases was performed to identify adult human studies of at least 10 SSc patients with a primary focus of SHI that included data on cTn and BNP or NT-proBNP results. Only cohort studies and case-controlled studies were identified and the quality of the evidence presented in each study was assessed according to the Newcastle-Ottawa Quality Assessment Scale.
Of the 2742 studies identified by the database search, 12 articles fulfilled the study inclusion criteria. Three out of four studies evaluating SHI using cardiac magnetic resonance imaging found no association between cardiac biomarkers and imaging changes. By comparison echocardiographic abnormalities, cardiac arrhythmias and congestive cardiac failure were more likely to be associated with elevated cardiac biomarkers. Comparison of results between studies was limited by the highly heterogenous definitions of SHI and inclusion criteria employed across studies.
There are insufficient data to draw definitive conclusions about the role of cTn and BNP / NT-proBNP in the diagnosis of SHI. Currently available literature suggests that cardiac biomarkers may have some role, in conjunction with other diagnostic modalities, in identifying SHI; however, this remains a much-needed area of clinical research.
Interpreting troponin in renal disease: A narrative review for emergency clinicians
2020, American Journal of Emergency Medicine
Patients with chronic kidney disease (CKD)/end stage renal disease (ESRD) can experience several severe complications, including acute coronary syndrome (ACS). While troponin is the biomarker of choice for evaluation of ACS, interpretation of troponin in CKD/ESRD can be challenging.
This narrative review evaluates troponin elevation in patients with CKD/ESRD, pitfalls in the evaluation with troponin, and an approach to using troponin in these high-risk patients.
Patients with CKD/ESRD are at greater risk for ACS and possess higher levels of circulating troponin. Relatedly, these patients often present atypically for ACS. Several pitfalls must be considered in the use of troponin when evaluating for ACS. While troponin elevation in patients with CKD/ESRD is often considered to be due to underlying renal disease, this elevation has several etiologies including uremic skeletal myopathy, microinfarctions, left ventricular hypertrophy (LVH), decreased clearance, and unrecognized congestive heart failure (CHF). Utilizing troponin assays in this patient population requires a nuanced approach, as the sensitivity and specificity for troponin testing in CKD varies. Concern for ACS with elevated troponin warrants treatment for ACS until proven otherwise, with consideration of atypical presentations along with other causes for patient symptoms that may result in troponin elevation.
Patients with CKD/ESRD presenting with symptoms concerning for ACS are challenging. The utilization of troponin assays is important in this population given their high risk of ACS but requires an educated and nuanced approach.
Cardiac troponins in chronic kidney disease patients with special emphasis on their importance in acute coronary syndrome
2019, Advances in Medical Sciences
Troponin measurement is one of crucial assessments facilitating diagnosis of acute coronary syndrome. Patients with chronic kidney disease are decimated by cardiovascular disease. Unfortunately, elevated concentration of serum troponin is commonly faced in clinical practice creating a challenge to rule out acute cardiac ischaemia in this vulnerable population. This review presents current knowlegde on analytical differences in troponin T and I measurements, their prognostic significance and their application in diagnosing acute coronary syndrome in chronic kidney disease patients. It also points out poorly known aspects and suggests directions for future research.
Heart Failure in End-Stage Kidney Disease: Pathophysiology, Diagnosis, and Therapeutic Strategies
2018, Seminars in Nephrology
Summary: Heart failure (HF) is a major comorbidity in patients with end-stage kidney disease (ESKD). The pathogenesis of HF in patients on renal replacement therapy represents the confluence of several traditional and nontraditional vascular risk factors, unique to the milieu of chronic kidney disease and the dialysis modality. The diagnosis of HF with ESKD is complicated by the background of frequent inevitable fluid shifts superimposed on underlying myocardial pump abnormalities and dialysis-induced myocardial stunning. A careful temporal assessment of symptoms and physical findings, cardiac imaging, hemodynamic data, and biomarkers help establish an accurate diagnosis of HF in ESKD. Accurate volume assessment and its tight management remains the cornerstone of treatment in HF in patients on dialysis. A multidisciplinary approach between the cardiologist and nephrologist in optimizing pharmacologic strategies for HF in this population, and dialysis-based options such as frequent dialysis, may help reduce the burden of HF in this vulnerable population. Finally, including patients with ESKD in clinical trials for HF therapies, and designing pragmatic trials that bring targeted strategies for HF into the daily clinical practice of dialysis, will shed light on the optimal management of the dual burden of cardiomyopathy and advanced kidney disease.
Comparison of the Association Between High-Sensitivity Troponin I and Adverse Cardiovascular Outcomes in Patients With Versus Without Chronic Kidney Disease
2018, American Journal of Cardiology
It is unknown whether the association of high-sensitivity troponin I (hs-TnI) with adverse cardiovascular outcomes varies by the presence of chronic kidney disease (CKD). We examined the association of hs-TnI with adverse cardiovascular outcomes in those with and without CKD in 4,107 (mean age, 64 years; 63% men; 20% black) patients from the Emory Cardiovascular Biobank who underwent coronary angiography. CKD (n = 1,073) was defined as estimated glomerular filtration rate <60 ml/min/1.73 m² or urine albumin/creatinine ratio >30 mg/g at baseline. Cox regression was used to compute hazard ratios (HR) for the association between hs-TnI levels (per doubling of hs-TnI: log₂[hs-TnI] + 1) and death, cardiovascular death, and major adverse cardiac events (MACE), separately. Hs-TnI was a stronger predictor of death (CKD: HR 1.23, 95% confidence interval [CI] 1.15 to 1.31; no CKD: HR 1.11, 95% CI 1.05 to 1.17, p-interaction = 0.023), cardiovascular death (CKD: HR 1.24, 95% CI 1.14 to 1.34; no CKD: HR 1.15, 95% CI 1.07 to 1.22, p-interaction = 0.12), and MACE (CKD: HR 1.18, 95% CI 1.11 to 1.25; no CKD: HR 1.11, 95% CI 1.06 to 1.16, p-interaction = 0.095) in CKD compared with non-CKD. The association between hs-TnI and death in patients with CKD was stronger for patients without obstructive coronary artery disease (no obstructive coronary artery disease: HR 1.60, 95% CI 1.27 to 2.01; obstructive coronary artery disease: HR 1.19, 95% CI 1.11 to 1.27, p-interaction = 0.041). In conclusion, hs-TnI is a stronger predictor of adverse cardiovascular events in patients who have CKD than those without, even in the absence of obstructive coronary artery disease. Hs-TnI may identify CKD patients who are high risk for adverse cardiovascular outcomes in whom aggressive risk factor modification strategies are warranted.
Relationships Between Left Ventricular Structure and Function According to Cardiac MRI and Cardiac Biomarkers in End-Stage Renal Disease
2017, Canadian Journal of Cardiology
We sought to assess the relationships between left ventricular (LV) remodelling and the mechanical and uremic stressors in hemodialysis patients.
In this prospective 2-centre cohort study, 67 prevalent hemodialysis patients were followed for 1 year. Data on routine bloodwork and predialysis blood pressure (BP) measurements were collected over a 12-week period. LV end-diastolic volume (LVEDV) and LV mass (LVM) were measured using cardiac magnetic resonance imaging and indexed. High-sensitivity troponin-I (hsTnI), N-terminal pro-brain natriuretic peptide (NT-proBNP), fibroblast growth factor 23 (FGF-23), and high-sensitivity C-reactive protein (hsCRP) were also measured. All study procedures were performed at baseline and at 1 year.
We examined the relationships between LV remodelling and (1) NT-proBNP and hsTnI (LV stretch and injury); (2) ultrafiltration volume (UFV) and interdialytic weight gain (IDWT; volume overload); (3) predialysis BP measurements (pressure overload); and (4) biomarkers of inflammation (hsCRP) and fibrosis (FGF-23).
LVEDV was significantly associated with UFV and with IDWT, at baseline as well as at 1 year. NT-proBNP was significantly and negatively correlated with UFV and IDWT, respectively, at 1 year. There were significant correlations between systolic BP and LVM index, at baseline and at 1 year as well as longitudinally. Systolic BP was the only parameter longitudinally correlated with LVM/LVEDV. hsTnI was not associated with urea, parathyroid hormone, calcium, phosphorus, FGF-23, hsCRP, or hemoglobin.
We did not observe significant relationships between myocardial injury and markers of fibrosis, inflammation, and LV remodelling. Elevated predialysis systolic BP, which might represent a common mediator of pressure and volume overload, appears to be a dominant stimulus for LV remodelling.
Nous avons cherché à déterminer les liens entre le remodelage ventriculaire gauche (VG) et les divers facteurs de stress mécanique et urémique chez les patients hémodialysés.
Dans le cadre de cette étude de cohorte prospective menée dans deux centres, 67 patients hémodialysés ont été suivi pendant une année. Les données des tests sanguins et des mesures de pression artérielle (PA) prédialyse ont été recueillies pendant une période de 12 semaines. Le volume intraventriculaire gauche en fin de diastole (VIGFD) et la masse du ventricule gauche (MVG) ont été mesurés à l’aide d’imagerie par résonance magnétique et indexés. On a aussi mesuré les taux de troponine I ultrasensible (hsTnI), de propeptide natriurétique de type B N-Terminale (NT-proBNP), du facteur de croissance des fibroblastes 23 (FGF-23) et de la protéine C-réactive ultrasensible (hsCRP). Toutes ces mesures ont été effectuées en début et en fin d’étude.
Nous avons examiné les possibles relations entre le remodelage VG et la présence 1) des NT-proBNP et hsTnI (étirement et lésion VG); 2) le volume d’ultrafiltration (VUF) et le gain de poids entre les séances de dialyse (poids cible entre les séances de dialyse; surcharge volémique); 3) les valeurs de PA prédialyse (surcharge de pression); et 4) les biomarqueurs d’inflammation (hsCRP) et de fibrose (FGF-23).
Le VIGFD était associé de manière significative au VUF et au poids cible entre les séances de dialyse, ce tant en début qu’en fin d’étude. Il y avait également une corrélation négative et significative entre le taux de NT-proBNP entre le VUF et le poids cible entre les séances de dialyse, respectivement, en fin d’étude. Il y avait corrélation significative entre la PA systolique et l’indice de MVG en début et en fin d’étude, de même que de manière longitudinale. La PA systolique était le seul paramètre à présenter une corrélation longitudinale avec la MVG et le VIGFD. Le taux d’hsTnI n’était pas, pour sa part, associé aux taux d’urée, de parathormone, de calcium, de phosphore, de FGF-23, de hsCRP ni d’hémoglobine.
Nous n’avons pas observé de liens significatifs entre les lésions du myocarde et les marqueurs de fibrose, d’inflammation et de remodelage VG. Une augmentation de la PA systolique prédialyse, qui pourrait à la fois signaler une surcharge volémique et une surcharge de pression, semble constituer le principal facteur de remodelage VG.

View all citing articles on Scopus

: For the Cardiovascular Risk Extended Evaluation in Dialysis Patients (CREED) investigators: Giuseppe Enia, MD, Vincenzo Panuccio, MD, Carmela Marino, Rocco Tripepi, Vincenzo Candela, MD, Onofrio Marzolla, MD, Carlo Labate, MD, and Filippo Tassone, MD.

: Address reprint requests to Carmine Zoccali, MD, Divisione di Nefrologia & Centro di Fisiologia Clinica del CNR, Via Sbarre Inferiori 39, 89131 Reggio Calabria, Italy. E-mail: [email protected]

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Original Investigations: Dialysis TherapiesTroponin is related to left ventricular mass and predicts all-cause and cardiovascular mortality in hemodialysis patients★

Abstract

Section snippets

Protocol

Study cohort

Results

Discussion

Am J Kidney Dis

Kidney Int

Kidney Int

Kidney Int

Am J Cardiol

J Am Coll Cardiol

Clin Biochem

J Chromatogr B Biomed Sci Appl

J Am Coll Cardiol

Am J Kidney Dis

Cardiac natriuretic peptides are related to left ventricular mass and function and predict mortality in dialysis patients

J Am Soc Nephrol

Prognostic value of cardiac troponin T and I elevations in renal disease patients without acute coronary syndromes: A 9-month outcome analysis

Nephrol Dial Transplant

Cardiac troponin T predicts long-term outcomes in hemodialysis patients

Clin Chem

Cardiac troponin T predicts mortality in patients with end-stage renal disease

Circulation

Original Investigations: Dialysis Therapies
Troponin is related to left ventricular mass and predicts all-cause and cardiovascular mortality in hemodialysis patients★