Chronic kidney disease CKD is strongly associated with very high mor - PDF document






 












! Chronic kidney disease (CKD) is strongly associated with very high mortalityrates and accelerated cardiovascular disease (CVD).1A main concern forindividuals with CKD is the incidence of CVD events, including coronary heartdisease, cerebrovascular disease, and peripheral vascular disease.2-7The proportionof long-term and elderly patients was markedly increased in patients with CKD in Original ArticleDOI 10.3349/ymj.2009.50.4.537pISSN: 0513-5796, eISSN: 1976-2437Yonsei Med J 50(4): 537-545, 2009 


 

 




 Yong Un Kang,and Soo Wan Kim Revised: November 30, 2008interest. Yonsei University College of Medicine 2009 INTRODUCTION (RD) on clinical outcomes that include death, complicationwith transfer to other hospitals in hospital courses or ; 2) mild RD, 2639.0 years, men 76.8%), 60 MATERIALS AND METHODS Renal Dysfunction in Acute Coronary Syndrome segment elevation myocardial infarction; 67.7%, non-ST-3.1. Hypertension was present in 46.3%; DM, 27.5%;current smoking, 63.9%; hyper

lipidemia, 2.3%; and 12.3%had a history of IHD. More severeRD was associated with Group IGroup IIGroup IIIGroup IV (n = 148)(n = 263)(n = 180)(n = 57)Age (yrs)51 1062 9.073 8.271 10.70.045Male (%)113 (76.4)202 (76.8)110 (61.1)40 (70.2)0.002)26 2.924 2.722 2.522 4.6NSHypertension56 (37.8)122 (46.4)83 (46.1)39 (68.4)0.001Diabetes mellitus30 (20.3)67 (25.5)55 (30.6)26 (45.6)0.02Smoking109 (73.6)176 (66.9)96 (53.3)33 (57.9)0.001Hyperlipidemia2 (1.4)8 (3.0)4 (2.2)1 (1.8)NSIHD history14 (9.7)26 (9.9)30 (16.7)9 (16.1)NSChest pain72 (48.6)130 (49.4)103 (57.2)33 (57.9)NSDyspnea5 (3.4)12 (4.6)24 (13.3)11 (19.3)SBP (mmHg)138 27132 28128 32128 46DBP (mmHg)86 1682 1780 2079 29Killip class1.1 0.41.2 0.61.6 0.92.3 1.2STEMI95 (64.2)182 (69.2)172 (70.6)35 (61.4)NSNSTEMI43 (29.1)71 (27.0)47 (26.1)20 (35.1)NS UA10 (6.8)10 (3.8)6 (3.3)2 (3.5)NSIHD, ischemic heart disease; SBP, systolic blood pressure; DBP, diastolic blood pressure; STEMI, ST-segment elevation myocardia Group IGroup IIGroup IIIGroup IV (n = 148)(n = 263)(n = 180)(n = 57)GFR (mL/min)115 41.875 8.548 8.214 11.9Creatinine (mg/dL)0.8 0.20.9 0.21.2 0.72.8 2.5Troponin T (

ng/mL)5.0 5.96.3 8.36.5 10.77.9 8.6NSTroponin I (ng/mL)53.6 85.658.7 77.759.6 74.285.5 94.4NSCK-MB (U/L)101.9 116.397.2 108.4104.6 120114.4 177.9NSHgb (g/dL)14.0 1.813.7 2.712.5 2.112.1 2.3TC (mg/dL)185 35179 37172 41166 450.005LDL-C (mg/dL)122 32118 35112 36107 430.013hs-CRP (mg/dL)1.6 2.51.6 2.43.0 4.13.8 3.8NT-proBNP (pg/mL)798 11231185 19823958 585412791 13481 LVEF (%)59 1057 1251 1450 130.001 RESULTS RD. Cardiogenic shock in 20 patients; AV block in 10 Group IGroup IIGroup IIIGroup IV (n = 148)(n = 263)(n = 180)(n = 57)Coronary angiography (%)147 (99.3)263 (100)179 (99.4)53 (93.0)0.000Infarct-related artery (%)NSLeft anterior descending artery63 (50.0)109 (44.9)80 (47.3)23 (44.2)NSLeft circumflex artery20 (15.9)39 (16.0)25 (14.8)9 (17.3)NSRight coronary artery42 (33.3)89 (36.6)62 (36.7)18 (34.6)NSLeft main stem1 (0.8)2 (2.5)2 (1.2)2 (3.8)NSInvolved vessel number (%)0.0061 vessel74 (58.7)122 (50.2)78 (46.2)12 (23.1)0.0002 vessels32 (25.4)61 (25.1)41 (24.3)16 (30.8)NS3 vessels18 (14.3)44 (18.1)38 (22.5)19 (36.5)0.006Left main, isolated2 (1.6)14 (5.8)11 (6.5)5 (9.6)NSLeft main, complex0 (0)2 (0.8)1 (0.6)0 (0)N

SACC / AHA classification (%)NSB144 (34.9)88 (36.2)44 (26.0)16 (30.8)NSB242 (33.3)8 (28.0)54 (32.0)12 (23.1)NSC40 (31.7)87 (35.8)71 (42.0)24 (46.2)NSTIMI flow (%)NSTIMI 061 (48.4)109 (44.9)74 (43.8)26 (50.0)NSTIMI 15 (4.0)9 (3.7)11 (6.5)0 (0)NSTIMI 227 (21.4)59 (24.3)44 (26.0)9 (17.3)NS TIMI 333 (26.2)66 (27.2)40 (23.7)17(32.7)NS and 33.3% in those with severe RD. The incidence ofmyocardial infarction and stroke were higher in patientswith more severe RD. A graded association was observedbetween severity of RD and the risk of in-hospital death,complication and CCU stay of ACS, and the incidence ofMACE during follow-up. Fig. 1 illustrates Kaplan-Meier survival in patients withACS according to renal function during follow-up. SevereRD group showed lower probability of event-free survivalcompared with the other groups.Cox regression analysis for MACE during follow-upTable 6 lists factors found to be significant independentpredictors of MACE in the adjusted Cox proportionalhazards model. Severe RD [hazard ratio, 2.731; 95% con-fidence interval (CI), 1.058 to 7.047, p= 0.038], but notRenal Dysfunction in Acute Corona

ry Syndrome Outcomes according to the Estimated Glomerular Filtration Rate OutcomesGroup IGroup IIGroup IIIGroup IVIn-hospital outcome(n = 148)(n = 263)(n = 180)(n = 57)Death (%)0 (0)2 (0.8)7 (3.9)17 (29.8)Complications (%)6 (4.2)35 (13.4)37 (20.6)27 (47.4)Acute kidney injury0001Cardiogenic shock1142019Major bleeding0102AV block413108Ventricular tachycardia11376CCU stay (days)1.9 1.42.4 2.03.7 3.44.5 4.9Out-hospital outcome(n = 142)(n = 243)(n = 154)(n = 30)MACE (%)18 (12.7)32 (13.2)24 (15.6)10 (33.3)0.026Cardiac death1 (0.7)2 (0.8)4 (2.6)0 (0)NSMyocardial infarction5 (3.5)6 (2.5)9 (5.8)6 (20.0)0.000Re-PCI16 (11.3)30 (12.3)17 (11.0)6 (20.0)NSTVR13 (9.2)20 (8.2)11 (7.1)6 (20.0)NSNon-TVR1 (0.7)4 (1.6)0 (0)0 (0)NSTLR5 (3.5)6 (2.5)6 (3.9)0 (0)NSCoronary artery bypass graft0 (0)0 (0)1 (0.6)1 (3.3)NS Stroke0 (0)0 (0)0 (0)1 (3.3)0.027 Group IGroup IIGroup IIIGroup IV (n = 148)(n = 263)(n = 180)(n = 57)Aspirin142 (95.9)250 (95.1)163 (90.6)53 (93.0)NSCalcium channel blocker18 (12.2)23 (8.7)18 (10.0)10 (17.5)NSBeta blocker128 (86.5)232 (88.2)148 (82.2)38 (66.7)ACE inhibitor124 (83.8)218 (82.9)149 (82.8)34 (59.6)Statin136

(91.9)227 (86.3)155 (86.1)35 (61.4)Vasopressor30 (20.3)66 (25.1)84 (46.7)32 (56.1)Diuretics22 (14.9)56 (21.3)87 (48.3)38 (66.7)Thrombolysis13 (8.8)32 (12.2)15 (8.3)4 (7.0)NSPCI124 (83.8)232 (88.2)161 (89.4)43 (75.4)0.031 CABG1 (0.7)7 (2.7)1 (0.6)1 (1.8)NS Yong Un Kang, et al. (hazard ratio, 1.155; 95% CI, 1.020 to1.307, CKD and mortality and morbidity after development ofACS, previous reports suggested that more severe RD wasartery disease.IHD in CKD patients suggested the importance of traditio-nal risk factors (hypertension, DM, smoking,and hyperlipi- Table 6.Cox Regression Analysis for Major Adverse Cardiac Event during Follow Up FactorsHazard ratio (95% CI)Normal renal function1Mild renal dysfunction0.992( 0.526 - 1.871)NSModerate renal dysfunction1.190 (0.534 - 2.651)NSSevere renal dysfunction2.731 (1.058 - 7.047)0.038Hypertension0.893 (0.569 - 1.402)NSDiabete mellitus1.367 (0.858 - 2.179)NSSmoking1.275 (0.609 - 2.672)NSSex1.439 (0.661 - 3.130)NSHyperlipidemia0.949 (0.224 - 4.011)NSOld age1.010 (0.985 - 1.036)NSLow hemoglobin1.155 (1.020 - 1.307)0.022Thrombolysis0.739 (0.317 - 1.726)NSPCI2.508 (0.951 - 6.61

6)NSCoronary artery bypass graft0.913 (0.518 - 1.927)NSAspirin1.403 (0.622 - 3.161)NSBeta-blocker0.908 (0.439 - 1.876)NSACEi1.133 (0.587 - 2.211)NSCalcium channel blocker0.970 (0.453 - 2.076)NS Statin0.456 (0.242 - 0.857)0.015 Time (days) 0.6 0.8 1.0 400 600 800 p Fig. 1.Kaplan-Meier survival in patients with acute coronary syndromeaccording to renal function during follow-up. Severe renal dysfunction groupshowed lower probability of event-free survival than the other groups. of ACS, CCU stay, and newly developed MACE includ-CVD in CKD patients. ACKNOWLEDGEMENTS 1. Sarnak MJ, Levey AS, Schoolwerth AC, Coresh J, Culleton B,Hamm LL, et al. 2. Tonelli M, Wiebe N, Culleton B, House A, Rabbat C, Fok M, etal. Chronic kidney disease and mortality risk: a systematic3. Muntner P, He J, Hamm L, Loria C, Whelton PK. Renal insuffi-4. Manjunath G, Tighiouart H, Ibrahim H, MacLeod B, Salem DN,Griffith JL, et al. Level of kidney rosclerotic cardiovascular outcomesin 5. Anavekar NS, McMurray JJ, Velazquez EJ, Solomon SD, KoberL, Rouleau JL, et al. Relation between renal dysfunction and car-6. Go AS, Chertow GM, Fan D, McCulloch

CE, Hsu CY. Chronic7. Weiner DE, Tighiouart H, Amin MG, Stark PC, MacLeod B,Griffith JL, et al. Chronic kidney disease as a risk factor for8. Ahn SJ, Choi EJ. Renal Replacement Therapy in Korea: Insan9. Shlipak MG, Heidenreich PA, Noguchi H, Chertow GM, Browner10. Wright RS, Reeder GS, Herzog CA, Albright RC, Williams BA,Dvorak DL, et al. Acute 11. Beattie JN, Soman SS, Sandberg KR, Yee J, Borzak S, Garg M,et al. Determinants of mortality after myocardial infarction inpresentation of renal disease in randomized controlled trials of13. Panetta CJ, Herzog CA, Henry TD. Acute coronary syndromes in14. Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendrik-sen S, et al. Using standardized serum creatinine values in the15. Roberts WL, Moulton L, Law TC, Farrow G, Cooper-AndersonM, Savory J, et al. Evaluation of nine automated high-sensitivity16. Prontera C, Emdin M, Zucchelli GC, Ripoli A, Passino C, A. Analytical performance and diagnostic accuracy of a fully-17. Ryan TJ, Faxon DP, Gunnar RM, Kennedy JW, King SB 3rd,18. van Domburg RT, Hoeks SE, Welten GM, Chonchol M, ElhendyA, Poldermans D. Renal insufficiency

and mortality in patients19. Walsh CR, OÕDonnell CJ, Camargo CA Jr, Giugliano RP, Lloyd-20. Al Suwaidi J, Reddan DN, Williams K, Pieper KS, HarringtonRA, Califf RM, et al. Prognostic implications of abnormalities in21. Shlipak MG, Fried LF, Cushman M, Manolio TA, Peterson D,23. DeFilippi C, van Kimmenade RR, Pinto YM. Amino-terminal24. Kalantar-Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD.Gutierrez A, Lindholm B, et al. Factors predicting malnutrition in27. Pecoits-Filho R, HeimbŸrger O, B‡r‡ny P, Suliman M, Fehrman-28. Ross R. Atherosclerosis--an inflammatory disease. N Engl J Med29. Menon V, Greene T, Wang X, Pereira AA, Marcovina SM, Beck30. Culleton BF, Larson MG, Wilson PW, Evans JC, Parfrey PS, Renal Dysfunction in Acute Coronary Syndrome 31. Walker AM, Schneider G, Yeaw J, Nordstrom B, Robbins S,32. Keough-Ryan TM, Kiberd BA, Dipchand CS, Cox JL, Rose CL,34. Grune T, Sommerburg O, Siems WG. Oxidative stress in anemia.36. Lonn E, Grewal J. Drug therapies in the secondary prevention of37. Hyre AD, Fox CS, Astor BC, Cohen AJ, Muntner P. The impact38. Nissen SE, Tuzcu EM, Schoenhagen P, Crowe T, Sasiela