Prognostic value of troponin T and I among asymptomatic patients with end-stage renal disease: a meta-analysis

Division of Internal Medicine, University of British Columbia, Canada.
Circulation (Impact Factor: 14.43). 11/2005; 112(20):3088-96. DOI: 10.1161/CIRCULATIONAHA.105.560128
Source: PubMed


The prognostic usefulness of troponin enzymes in end-stage renal disease (ESRD) patients is controversial. To resolve this uncertainty of troponin as a prognostic tool, we conducted a systematic review to quantify the association between elevated troponin I or T and long-term total mortality among ESRD patients not suspected of having acute coronary syndrome.
We conducted an unrestricted search from the MEDLINE, EMBASE, and DARE bibliographic databases to December 2004 using the terms or exp troponin and exp kidney, exp renal, exp kidney disease exp renal replacement therapy. We also manually searched review articles and bibliographies to supplement the search. Studies were included if they were prospective observational studies, used cardiac-specific troponin assays, and evaluated long-term risk of death or cardiac events for asymptomatic ESRD patients. Two authors independently abstracted data on study and patient characteristics. Studies findings were stratified according to troponin T or I levels. We used a random-effects model to pool study results and tested for heterogeneity using chi2 testing and used funnel-plot inspection to evaluate the presence of publication bias. Data from 28 studies (3931 patients) published between 1999 and December 2004 were included in this review. Patients received dialysis for a median duration of 4 years, with a mean follow-up of 23 months. From the pooled analysis, elevated troponin T (>0.1 ng/mL) was significantly associated with increased all-cause mortality (relative risk, 2.64; 95% CI, 2.17 to 3.20). Although the prognostic effect sizes were all consistent with a positive relationship between troponin T and mortality, there was significant heterogeneity in the magnitude of these effect sizes (P=0.015). The funnel plot showed evidence of publication bias. Elevated troponin T was also strongly associated with increased cardiac death. Studies evaluating troponin I included a wide variety of assays and differing cut points, rendering synthesis of the study findings difficult.
Elevated troponin T (>0.1 ng/mL) identifies a subgroup of ESRD patients who have poor survival and a high risk of cardiac death despite being asymptomatic. These findings suggest that troponin T is a promising risk stratification tool and may help frame therapeutic decisions. The clinical interpretation of elevated troponin I levels, however, remain unclear, largely because of the lack of standardization of assays.

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Available from: Christopher Richard Thompson, Jan 24, 2014
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    • "In pazienti asintomatici per cardiopatia ischemica ovvero per scompenso cardiaco congestizio , ma affetti da CKD ovvero ESRD, la presenza di elevati livelli sierici di troponina (valutati con tecniche di dosaggio di prima generazione) è associata con un rischio maggiore di eventi cardiovascolari avversi e di mortalità per tutte le cause [19] [19] (full text) [20] [20] (full text) [21] [21] (full text) [22] [22] [23] [23] (full text). "
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    ABSTRACT: Coronary thrombosis was recognized since 19th century as clinical entity with bad outcomes; only in 1912 it was reported that acute myocardial infarction had to been distinguished from angina pectoris. First diagnostic test was electrocardiogram, while white blood cells count and erythrocytes sedimentation rate were the only available laboratory tests Late in the 60s and 70s glutammic oxaloacetic and glutamic pyravate transaminase, lactate dehydrogenase and creatine kinase were added to biomarkers pool to provide a diagnosis of myocardial infarction related to myocardial cells injury. Only in 1987 assays for cardiac troponin were developed to assess structural damage of myocardial cells and in 2010 high sensibility troponins first dosage kits became available. It is well known that the population with chronic kidney disease (CKD) is at greater risk for cardiovascular disease and death than the general population. The use and interpretation of high sensitivity cardiac troponin (hs-cTn) assays have been particularly challenging in these patients with the majority having elevated levels at baseline Aim of this review is to evaluate hs-cTn in patients with CKD for the diagnosis of AMI and for the prognostic significance of elevated levels in CKD patients without AMI.
    07/2015; 32(4).
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    • "Some authors have described absolute levels of serum TnI in the diagnosis of BCI [17] [20], but there is no consensus for the absolute cut-off of serum TnI for the diagnosis. It has been shown in a number of studies that patients with troponin elevation not related to ischaemic cardiac disease have a worse prognosis [24] [25] [26]. Due to the numerous types of assays available for serum TnI with varying reference ranges, it is practical to take a value above the 99th centile for the diagnosis of acute myocardial dysfunction as significant in blunt thoracic trauma, as we did in this study. "
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    ABSTRACT: Purpose This study describes the incidence and outcomes of blunt cardiac injury (BCI) in a single trauma intensive care unit (TICU), together with the spectrum of thoracic injuries and cardiac abnormalities seen in BCI. Methods We performed a retrospective observational study of 169 patients with blunt thoracic trauma admitted from January 2010 to April 2013. BCI was diagnosed using an elevated serum troponin in the presence of either clinical, ECG or transthoracic echocardiography (TTE) abnormalities in keeping with BCI. The mechanism of injury, associated thoracic injuries and TTE findings in these patients are reported. Results The incidence of BCI among patients with blunt thoracic trauma was 50% (n = 84). BCI patients had higher injury severity scores (ISS) (median 37 [IQR 29–47]; p = 0.001) and higher admission serum lactate levels (median 3.55 [IQR 2.4–6.2], p = 0.008). In patients with BCI, the median serum TnI level was 2823 ng/L (IQR 1353–6833), with the highest measurement of 64950 ng/L. TTEs were performed on 38 (45%) patients with BCI, of whom 30 (79%) had abnormalities. Patients with BCI had a higher mortality (32% vs. 16%; p = 0.028) and trended towards a longer length of stay (17.0 days [standard deviation (SD) 13.5] vs. 13.6 days [SD 12.0]; p = 0.084) Conclusions BCI was associated with an increased mortality and a trend towards a longer length of stay in this study. It is a clinically relevant diagnosis which requires a high index of suspicion. Screening of high risk patients with significant blunt thoracic trauma for BCI with serum troponins should be routine practise. Patients diagnosed with BCI should undergo more advanced imaging such as TTE or TOE to exclude significant cardiac structural injury.
    Injury 09/2014; 46(1). DOI:10.1016/j.injury.2014.08.051 · 2.14 Impact Factor
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    • "Patient related, system related, and physician related factors may all contribute and may to a greater or lesser extent be modifiable. Patient related factors shown to be potential contributors include serum urea, creatinine, sodium, osmolarity, albumin, troponin and acute illness severity [1] [2] [3] [4] [5] [6] [7]. The establishment of an Acute Medical Admissions Unit (AMAU) is an example of a potential system factor contributing to outcomes, as is the setting of health care targets [8] [9]. "
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    ABSTRACT: There are little data on the experiential learning of certified consultant specialists and outcomes in acute medicine. We have examined the 30-day in-hospital mortality and hospital length of stay (LOS) in relation to practice duration, using a database of emergency admissions. All emergency admissions (60,864 episodes in 35,168 patients) over eleven years (January 2002 to December 2012) were evaluated. Consultant staff were categorised by duration of clinical practice as <15years, 15-20years, >20≤25years and >25years. We used a stepwise logistic regression model to predict 30-day in-hospital death, adjusting risk estimates for major predictor variables. Marginal analysis used adjusted predictions to test for interactions of key predictors, while controlling for other variables. Thirty-day in-hospital mortality correlated with time in clinical practice; decreasing from 8.9% and 9.1% with <15 and 15-20years to 7.7% for each of the categories of >20≤25years and >25years. There was a progressive shortening of LOS with extent of clinical practice - from a median 5.0days (IQR 1.8, 10.3) for consultants within 15 years of registration to 4.6 (IQR 1.7-8.9; p<0.05) at >20≤25years and 4.4 (IQR 1.7-9.0; p<0.01) with >25years. Duration of clinical practice predicted mortality in the univariable analysis - odds ratio (OR) 0.85 (95% CI: 0.78, 0.91; p<0.001); when adjusted in a multivariable model, it remained independently predictive - OR 0.87 (95% CI: 0.79, 0.96; p<0.001) for 30-day in-hospital mortality. Certified specialists appear to continue with experiential learning with evidence of improved outcome after 20years in clinical practice.
    European Journal of Internal Medicine 01/2014; 25(2). DOI:10.1016/j.ejim.2013.12.012 · 2.89 Impact Factor
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