Elevated troponin in chronic kidney disease associated with increased mortality

1.  From a systematic review, elevated troponin levels were associated with increased all-cause mortality and adverse cardiovascular events among those with chronic kidney disease. 

Evidence Rating Level: 1 (Excellent) 

Study Rundown: Serum troponin is a well-established measurement of myocardial damage in acute coronary syndrome (ACS). However, patients with chronic kidney disease (CKD) tend to have chronically elevated troponin levels.  Thus, it has remained unclear how such testing could inform prognosis. From a systematic review of studies of patients with CKD without suspected ACS, elevated troponin level was associated with increased cardiovascular and overall mortality in those patients who were receiving dialysis.  A similar effect was found in those not receiving dialysis, and the outcomes were comparable whether troponin I or troponin T was measured. The greatest limitation of this study is its application, as CKD is already known to increase risk of coronary artery disease (CAD), and it is unknown what clinical action should be in response to troponin testing. Overall, this study suggests that increased troponin levels correlate with a worse prognosis in those with CKD, regardless of whether they are undergoing dialysis.

Click to read the study, published today in the Annals of Internal Medicine

Relevant Reading: Prognostic value of serum cardiac troponin I in ambulatory patients with chronic renal failure undergoing long-term hemodialysis: A two-year outcome analysis

In-Depth [systematic review]: T98 studies were included for review, all observational cohort studies. For the all-cause mortality of troponin T and troponin I those undergoing dialysis, the pooled hazard ratios (HR) were 3.0 [95%CI=2.4-4.3] and 2.7 [95%CI=1.9-4.6] respectively, and the pooled odds ratios (OR) were 4.7 [95%CI=3.6-6.5] and 2.6 [95%CI=1.9-3.6] respectively. A similar increase in cardiovascular mortality HR and OR was found, as well as for major adverse cardiovascular events (MACEs). There were fewer studies to analyze for those not undergoing dialysis, but the troponin T level was associated with a pooled HR of 3.4 and a pooled OR of 3.0, and only 2 studies investigated the effect of an elevated troponin I. There was significant heterogeneity within many of the studies included in the analysis, and there was a wide variety of the type of troponin measurements and cut-offs. Therefore, it is possible that a reporting bias may have influenced this review. Although the results of this review allow for greater risk stratification of those with CKD based on elevated troponin levels, it remains unclear how it should affect clinical management.

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Image: PD 

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