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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 5  |  Page : 789-793
C- Reactive protein, cardiac troponin T and low albumin are predictors of mortality in hemodialysis patients


Taleghani Medical Center (Nephrology and Transplantation Ward), Shahid Beheshti Medical University, Tehran, Iran

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Date of Web Publication2-Sep-2009
 

   Abstract 

Overall and cardiovascular mortality are significantly higher in hemodialysis patients with elevated C-reactive protein (CRP). The aim of study was to determine whether CRP, low albumin and troponin are markers of overall and cardiovascular mortality in hemodialysis patients. 138 stable hemodialysis patients were divided into 2 groups n= 66 patients with coronary disease equivalent (known coronary or peripheral vascular disease or diabetes mellitus) and n= 72 patients without it. The two groups were then stratified by biomarkers [cardiac troponin T and Albumin and highly sensitive CRP (hs-CRP)] and followed for 30 months. The primary outcome was all causes mortality. Patients with coronary disease equivalents had 3.5 fold greater annual mortality compared to controls (24%% vs 6.9%, P value = 0.005). Elevated troponin T had a further increase in the risk for death while hs-CRP and low albumin were not associated with risk of death In conclusion, circu­lating cardiac troponin-T was associated with poor prognosis especially in hemodialysis patients with coronary risk factors.

How to cite this article:
Bagheri N, Taziki O, Falaknazi K. C- Reactive protein, cardiac troponin T and low albumin are predictors of mortality in hemodialysis patients. Saudi J Kidney Dis Transpl 2009;20:789-93

How to cite this URL:
Bagheri N, Taziki O, Falaknazi K. C- Reactive protein, cardiac troponin T and low albumin are predictors of mortality in hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2019 Dec 8];20:789-93. Available from: http://www.sjkdt.org/text.asp?2009/20/5/789/55362

   Introduction Top


Maintenance hemodialysis (HD) patient's ex­hibit increased cardiovascular mortality and vas­cular events account for more than half of deaths in this population. [1]

The stratification of asymptomatic patients with end stage renal disease (ESRD) into higher and lower risk groups would be useful for iden­tifying patients who might benefit from aggre­ssive evaluation and treatment.

Previous studies have suggested that troponins could be a predicative tool in coronary heart di­sease in ESRD. [1],[2] However, troponin levels in the HD patients could be influenced by factors other than ischemic damage such as retention due to lack of excretion or uremic cardiomyo­pathy. [3]

We proposed that dividing stable patients with ESRD on maintenance HD into different clini­cal subsets by presence or absence of known coronary disease equivalent would lead to clearer risk stratification by abnormal cardiac troponin T as well as hs-CRP and albumin.


   Methods Top


138 hemodialysis patients from three hemo­dialysis centers were evaluated from June 2005 to December 2007.

Demographic and medical data were obtained from patients' interviews, chart reviews and hos­pital information system. Inclusion criteria in­cluded all of patients who were on maintenance HD for > 6 months.

The exclusion criteria included:

  1. Systemic inflammation such as active auto­immune disease, infectious diseases
  2. Ongoing ischemia or any revascularization procedure during recent 8 weeks. Informed consent was obtained from all patients.
The primary outcome variable was all cause mortality. Mortality data was collected by sear­ching death records, from hospital charts, and through family phone interviews.

Diabetic patients or patients who had periphe­ral vascular disease were classified as patients having potential coronary artery disease. Patients with previous documented myocardial infarction or a history of surgical or percutaneous coro­nary revascularization, were defined as having coronary artery disease.

Peripheral vascular disease was defined as ha­ving any of the following: carotid artery steno­sis of > 50%, abdominal or thoracic aortic aneu­rysm and peripheral arterial disease. Blood sam­ple for hs-CRP and troponin T were measured before the beginning of mid week hemodialysis session for three consecutive months.

Serum troponin T level were measured by elec­trochemiluminescence immune assay and hs­CRP by nephlometry (CV < 1%). The manu­factures stated detection limit was < 0.01 mg/L with the 99 th percentile for reference population being 0.01 mg/L. Laboratory personnel were unaware of patient's clinical data. Following the recommendation of Center for Disease Control and Prevention and the American heart associa­tion [4] the 2 clinical groups (patients with coro­nary disease and those without) were further stratified by hs-CPR values(< 3 and > 3 mg/L) and C-TnT was defined as being < 0.05 mg/L and > 0.05 mg/L.

Patients were divided into two groups. Group I: patient who had coronary disease. Group II: with no history of coronary artery disease or risk factors.

Cardiac troponin T and hs-CRP and mortality were compared between two groups.


   Statistical analysis Top


Clinical variable are reported as mean ± SD and categorical variable as percentages. Fishers exact test was used to compare categorical va­riables, and continuous variables were evalua­ted using unpaired student ' s t test. P< 0.05 was taken as significant and analysis was done using SPSS (Chicago, USA).


   Result Top


Among a 138 stable HD patients Group I in­cluded n=66 with coronary artery disease equi­valent (diabetes mellitus, known of coronary or peripheral vascular diseases), whereas Group II n= 72 as controls. The baseline characteristics of the patients are listed in [Table 1]. During 30 month follow up, 24 (17.4%) patients died. Death was attributed to cardiovascular diseases in 16 patients and infectious cause in 5 patients.

Three patients died of unknown cause. Mor­tality in Group I was (24%) 16/66 and Group II was 8.06% (5/72).

Hs-CRP elevated (> 3mg/L) in (n= 32) 23.1% patients. C-TnT was found to be elevated in (40%) (n= 56/138) of patients. C-TnT was higher in Group I compared to Group II 46/66 (69.6%) vs 10/72 (13/8%) (P value = 0.03), [Table 2].

In Group I patients with elevated C-TnT > 0.1 ng/dL had 3.5 fold greater mortality (24.2% vs 6.9%, P= 0.005).

Hs-CRP (> 3 mg/L) evaluated in group I did not add to the mortality risk. Both groups had si­milar high serum levels of hs-CRP (group I: n= 7 vs group II: n= 4, P= 0.24), [Table 2] but mor­tality was higher in patients with high hs-CRP (34% vs 9%) without considering the CAD risk factors.

There was not any significant difference bet­ween serum albumin levels in the two groups.


   Discussion Top


Serum C-TnT and hs-CRP elevated in hemo­diaysis patients, posses a common clinical prob­lem in patients with ESRD. Several studies have supported that elevation of C-TnT and hs-CRP as predictors of increased mortality. [5],[6],[7],[8]

In our study, we evaluated the clinical risks for coronary artery disease in association with the.

The findings of the present study are compa­tible with previous studies but are unique in se­veral aspects.

We found that large percentage of asympto­matic patients with ESRD have elevations of C­-TnT, compatible with other studies. [5],[6],[9] Our study also confirmed that C-TnT is independent pre­dictor of all cause mortality in these patients further more cTnT alone had better predictive value than C-reactive protein (CRP) alone for mortality and first cardiovascular events. [10]

As it is shown in [Table 1], the age and duration of hemodialysis in group 1 was higher (P< 0.05) compared to younger age group with coronary artery disease reported in an earlier study. [11]

Our studies showed serum albumin and hs­CRP were not significantly different in two groups although pervious studies describe that serum CRP and albumin in ESRD patients are strong predictors for cardiovascular mortality. [12],[13] .This may be due to the small sample size in our patients. The most common cause of mortality in HD patients is cardiovascular diseases (CVD), while the most common cause of co-morbidity is infections [16] which is associated with higher CRP levels compared with cardiac death. [17] .

The CRP levels are highly variable and in­fluenced by intercurrent events in dialysis pa­tients. Use of statins may reduce the CRP levels although these agents are not shown to reduce the cardiovascular mortality in diabetic dialysis patients. [18]

Furthermore, higher levels of cTnT may iden­tify patients with severe angiographic coronary disease. [19]

Our patients in Group I had significant cardiac disease as shown in [Table 1]; prevalence of dys­lipidemia and heart failure was higher in this group.

In addition some studies have not found an association between malnutrition/inflammation and an increased risk of atherosclerosis among dialysis patients [20],[21] which is compatible to some extent with our study also.

In conclusion, C-TnT per se is more helpful in risk stratifying of patients with ESRD and coro­nary disease equivalent. Elevated hs-CRP and low albumin level was not associated with coro­nary artery disease related mortality and may be a better predictor of death due to inflammation and infection in further larger studies in main­tenance HD patients.

 
   References Top

1.Khan IA, Wattanasuwan N, Mehta NJ, et al. Prognostic value of serum cardiac troponin I in ambulatory patients with chronic renal failure undergoing long term hemodialysis: a two years outcome analysis. J Am Coll Cardiol 2000;38: 991-8.  Back to cited text no. 1    
2.Chen P, Tanasejivic M. Use of serum cardiac troponin-I level in dialysis patients. Semin Dial 2000;13:58-9.  Back to cited text no. 2    
3.London GM. Cardiovascular disease in chronic renal failure pathophysiologic aspect. Semin Dial 2003;16:85-94.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Pearson TA, Mensah GA, Alexander RW, et al. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: a statement for healthcare professio­nals from the Centers for Disease Control and Prevention and the American Heart Association. Circulation 2003;107:499-511.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Apple FS, Murakami MM, Pearce LA, Herzog CA. Predictive value of cardiac troponins I and T for subsequent death in end stage renal disease. Circulation 2002;106:2941-5.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Roppolo LP, Fitzgerald R, Dillow J, Ziegler T, Rice M, Maisel A. A comparison of troponin T and troponin I as predictors of cardiac events in patients undergoing chronic dialysis at a veteran's hospital: a pilot study. J Am Coll Cardiol 1999;34:448-54.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Zimmerman J, Herrlinger S, Pruy A, Metzger T, Wanner C. Inflammation enhances cardiovascular risk and mortality in hemodialysis patients. Kidney Int 1999;55:648-58.  Back to cited text no. 7    
8.Yeun J, Levine RA, Mantadilok V, Kaysen GA. C-reactive protein predicts all-cause and cardio­vascular mortality in hemodialysis patients. Am J Kidney Dis 2000;35:469-76.  Back to cited text no. 8    
9.Fehr T, Knoflach A, Ammann P, Pei P, Binswanger U. Differential use of cardiac troponin T versus I in hemodialysis patients. Clin Nephrol 2003;59:35-9.  Back to cited text no. 9  [PUBMED]  
10.Wang AY, Lam CW, Wang M, et al. Prognostic value of cardiac troponin T is independent of inflammation, residual renal function, and car­diac hypertrophy and dysfunction in peritoneal dialysis patients. Clin Chem 2007;53(5):882-9.  Back to cited text no. 10    
11.Kanwar M, Hashem M, Rosman H, et al. Use­fulness of clinical evaluation, troponins, and C­reactive protein in predicting mortality among stable hemodialysis patients. Am J Cardiol 2006;98:1283-7.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Yeun JY, Levine RA, Mantadilok V, Kaysen GA. C-Reactive protein predicts all-cause and cardiovascular mortality in hemodialysis patients. Am J Kidney Dis 2000;35:469.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Owen WF, Lowrie EG. C-reactive protein as an outcome predictor for maintenance hemo­dialysis patients. Kidney Int 1998;54:627-63.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.deFilippi C, Wasserman S, Rosanio S, Tiblier E. Cardiac troponin T and C-reactive protein for predicting prognosis, coronary atherosclerosis, and cardiomyopathy in patients undergoing long-term hemodialysis. JAMA 2003;290:353.  Back to cited text no. 14    
15.Akdag I, Yilmaz Y, Kahvecioglu S, et al. Cli­nical value of the malnutrition-inflammation athe­rosclerosis syndrome for long term prediction of cardiovascular mortality in patients with end stage renal disease: a 5-year prospective study. Nephron Clin Pract 2008;108(2):c99-c105.  Back to cited text no. 15    
16.Sit D, Kadiroglu AK, Kayabasi H, Kara IH, Yilmaz Z, Yilmaz ME. The evaluation incidence and risk factors of mortality among patients with end stage renal disease in Southeast Turkey. Ren Fail 2008;30(1):37-44.  Back to cited text no. 16    
17.Koch M, Haastert B, Trapp R. The prognostic value of the C-reactive protein levels in HD patients with death risk from infection. Clin Nephrol 2007;68(1):18-25  Back to cited text no. 17    
18.van der Sande FM, Kooman JP, Leunissen KM. The predictive value of C-reactive protein in end stage renal disease: is it clinically signi­ficant? Blood Purif 2006;24(4):335-41.  Back to cited text no. 18    
19.deFilippi C, Wasserman S, Rosanio S, et al. Cardiac troponin T and C-reactive protein for predicting prognosis, coronary atherosclerosis, and cardiomyopathy in patients undergoing long­term hemodialysis. JAMA 2003;290(3):353-9  Back to cited text no. 19    
20.Beddhu S, Pappas LM, Ramkumar N, Samore MH. Malnutrition and atherosclerosis in dialysis patients. J Am Soc Nephrol 2004;15:733.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]
21.Stenvinkel P, Heimburger O, Lindholm B. Wasting, but not malnutrition, predicts cardio­vascular mortality in end-stage renal disease. Nephrol Dial Transplant 2004;19:2181.  Back to cited text no. 21    

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Correspondence Address:
Nazila Bagheri
Taleghani Medical Center (Nephrology and Transplantation Ward), Shahid Beheshti Medical University, Tehran
Iran
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PMID: 19736474

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    Tables

  [Table 1], [Table 2]

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