HIGH-SENSITIVITY CARDIAC TROPONIN T AND C-REACTIVE PROTEIN HAVE DIFFERENT PROGNOSTIC VALUES IN HAEMO- AND PERITONEAL DIALYSIS POPULATION: A COHORT STUDY

T CHEN1, 5, H HASSAN2, 7, M VU4, 5, P Rao1, 5, A MAKRIS3, 6

1The Westmead Institute for Medical Research, Westmead, NSW; 2Wollongong Hospital, Wollongong, NSW; 3Liverpool Hospital, Liverpool, NSW; 4Royal Prince Alfred Hospital, Camperdown, NSW; 5University of Sydney, Camperdown, NSW; 6University of New South Wales, Kensington, NSW; 7University of Wollongong, Wollongong, NSW

Aim: To evaluate the prognostic value of high sensitivity cardiac troponin T (hs-cTnT) and C-reactive protein (CRP) in stable haemodialysis (HD) and peritoneal dialysis (PD) patients.

Background: In dialysis population, clinical assessment based on traditional risk factors is inadequate in identifying patients at high risk of adverse outcome. Serum biomarkers can be a useful tool in risk stratification of this population.

Methods: A 3.5-year retrospective observational study of a cohort of 574 HD (n=347) and PD (n=227) patients. All-cause mortality and major adverse cardiovascular events (MACE) were assessed. SPSSv23 was used, P<0.05 was significant.

Results: No patient was lost to follow up. For HD patients, hs-cTnT remained relatively stable for the follow up period. For PD patients, hs-cTnT increased significantly every year (P<0.001).

High-sensitivity cardiac troponin T was an independent predictor of both outcomes in HD and PD patients. C-reactive protein was an independent predictor of both outcomes in PD patients only. Performing CRP in addition to hs-cTnT further improved risk prediction. The area under the receiver operating curves (AUC) for hs-cTnT (mortality AUC=0.706, MACE AUC=0.62) and traditional clinical parameters (mortality AUC=0.703, MACE AUC=0.634) were similar and they were larger than CRP (mortality AUC=0.591, MACE AUC=0.523). Adding hs-cTnT to traditional clinical parameters significantly increased its AUC (P=0.018).

Conclusions:

  1. Both hs-cTnT and CRP have a useful role in predicting adverse outcomes in dialysis patients at 3.5 years. Their prognostic performance is different in HD and PD patients.
  2. Adding hs-cTnT to traditional clinical parameters significantly improves the its prognostic performance.
  3. The frequency of hs-cTnT measurement should be at least yearly for PD. For HD patients, a less frequent measurement may be acceptable.

FIRST CARDIOVASCULAR EVENT POST ENROLMENT IN CKD.QLD REGISTRY PATIENTS WITH DIABETES WHO HAVE UNDERGONE RENAL BIOPSY

KS TAN1,2,3, S NG3, J ZHANG1,2, Z WANG1,2, A CAMERON1,2, WE HOY1,2

1NHMRC CKD.CRE and CKD.QLD, Brisbane, Queensland; 2Faculty of Medicine, University of Queensland, Brisbane, Queensland; 3Renal unit, Logan Hospital & Metro South Health Service, Brisbane, Queensland.

AIMS: Determine the type of first Cardiovascular (CVS) event in patients with diabetes mellitus (DM) enrolled in the CKD.QLD registry who had undergone renal biopsy.

BACKGROUND: The CKD.QLD registry is a Queensland-wide registry of patients with chronic kidney disease (CKD) who are followed up in the state’s public hospital renal units and have provided informed consent. Enrolment commenced in 2011.

METHODS: Patients with DM enrolled in the registry between 22/01/2011 and 15/11/2016 inclusive with previous renal biopsy were included. Baseline characteristics, incidence and nature of the first CVS event post enrolment were determined. Censor date was 1/03/2017.

RESULTS: Among 2665 CKD patients with DM, 189 patients (84 women) had undergone renal biopsy. Mean follow up at censor date was 3.1 years. Mean age at enrolment was 60.2y (SD 12.5).  57 patients (30%) had known CVS disease at enrolment.

At censor date, 52 patients had experienced at least one CVS event. The commonest first CVS event which occurred in 35 patients (67%) was cardiac (acute coronary syndrome/coronary revascularization procedure/admission for acute heart failure). 37% of those who suffered a CVS event had at least one prior CVS event at time of enrolment compared to 28% of those who did not suffer a CVS event although this difference was not statistically significant (p= 0.24).

At censor date, 14 of these 52 patients (27%) had died without commencing renal replacement therapy (RRT) although three (6%) were already committed to supportive care. Eight patients (15%) had commenced RRT.

CONCLUSIONS: In this group of patients at high risk of CVS events, the commonest type of CVS event was cardiac. Known underlying CVS disease did not obviously increase risk.

RENAL ARTERY STENOSIS AS A CAUSE OF TAKOTSUBO CARDIOMYOPATHY

V SASONGKO1, R QASABIAN1,2, S MAY1

1Tamworth Rural Referral Hospital, Tamworth, NSW;  2Royal Prince Alfred, Sydney, NSW

Background: Takotsubo cardiomyopathy, a transient cardiac syndrome that mimics acute coronary syndrome, is thought to be precipitated by sympathetic nervous system activation. Renal artery stenosis (RAS) induces hypertension by several mechanisms, including the rise in serum cathecolamines. We describe a case of Takotsubo cardiomyopathy in a patient with RAS and propose a causal association between the two phenomenon.

Case report: A 78-year-old female haemodialysis patient with background history of hypertension and anxiety presented with acute dyspnoea, elevated troponin and anterior ST-segment changes on electrocardiogram. An echocardiogram performed three months earlier showed normal left ventricular systolic function with Ejection Fraction (EF) of 67%.

Our patient had recently commenced haemodialysis six weeks earlier following a presentation with acute kidney impairment (creatinine of 734mmol/l). She was noted to have small left kidney and a 11.6cm non-obstructed right kidney. Renal biopsy showed viable kidney with mild mesangial matrix expansion.

A repeat echocardiogram showed a severe left ventricular systolic dysfunction (EF of 32%) and coronary angiography was suggestive of Takotsubo cardiomyopathy with minimal coronary artery disease. A renal angiogram was performed at the same time due to our suspicion of RAS and this confirmed no identifiable flow to the right kidney.

Given the apparent viability of the right kidney, angioplasty and stenting of right renal artery was performed, resulting in dramatic improvement of dyspnoea, a return to normal cardiac function and a gradual recovery of renal function. Our patient is currently off dialysis with creatinine of 129mmol/l.

Conclusion: Renal artery stenosis can be suspected as a rare cause of Takotsubo Cardiomyopathy. Stenting of the stenosed renal artery may result in the recovery of renal function and cardiac function.

SUDDEN SEVERE HYPERTENSION: AN ATYPICAL MANIFESTATION OF PRIMARY HYERPARATHYROIDISM. A CASE REPORT

FERRIER C 1, CATTANEO F1, SOLCA C1, BRUNO V2

1Clinica Moncucco, Lugano Switzerland; 2University Hospital, Berne, Switzerland

Background: Calcium plays an important role in blood pressure (BP) regulation, probably through a direct effect on cardiovascular contractility. Hypercalcemia may rise BP by increasing adrenergic activity and vascular reactivity. Primary hyperparathyroidism(PHPT)-associated hypercalcemia is often asymptomatic and detected by routine blood tests. Although hypertension is common in PHPT, the clinical manifestation of PHPT may be atypical.

Case Report: We report a case of a 56 year old Caucasian woman with no H/O hypertension presenting sudden onset of vertigo with severe hypertension. Medical history was otherwise unremarkable, and clinical examination showed a BP of 215/150mmHg and a BMI of 32.2 kg/m2. Initial laboratory data revealed an elevated total serum calcium (2.79 mmol/l), low phosphate (0.83 mmol/L) and normal 24hr urinary calcium excretion (3.4 mmol/day). Other laboratory and radiological examinations excluded a vascular, renal (PCr 73mcmol/L, no proteinuria, normal urinary sediment), thyroid and adrenal disease and/or a pheochromocytoma. Further evaluation for suspected PHPT showed an elevated iPTH level of 182 ng/L (Normal range: 22.5-105) and a left parathyroid adenoma on ultrasound.

Conclusions: In the presence of chronic or acute hypertension PHPT should be excluded. The determination of serum calcium should be mandatory in any patient with suspected secondary form of hypertension.

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