High sensitivity Troponin-I levels in asymptomatic hemodialysis patients

Early detection of myocarditis caused by immune checkpoint inhibitor therapy with nivolumab and ipilimumab for advanced recurrent renal cell carcinoma

Combination therapy with nivolumab and ipilimumab for advanced renal cell carcinoma (RCC) may cause immune-related myocarditis; however, its incidence in this cancer type and regimen remains unknown. At our institution, we measure biomarkers, such as high-sensitivity Troponin (hsTn), and perform electrocardiograms (ECGs) and echocardiography before and every month after the initiation of this therapy, and the findings obtained and patients' symptoms are continuously monitored by physicians and pharmacists. A retrospective survey was conducted on physiological and biochemical test findings and immune-related adverse events in patients with advanced RCC who received combination therapy with nivolumab and ipilimumab between October 1, 2018 and December 31, 2023. Patients suspected of having myocarditis consulted with cardiologists. Myocarditis due to this therapy was detected in 5 of the 86 patients (5.8%) assessed using the European Society of Cardiology 2022 guidelines. There were no fatal symptoms or death due to myocarditis. The median time to the onset of myocarditis was 25 days (21-86 days). The early detection of myocarditis caused by this therapy requires the monitoring of changes by periodically measuring hsTn and other cardiac markers and performing ECGs and echocardiography from the early stages of administration through to the end of treatment. In addition to checking symptoms, if these abnormalities are detected and myocarditis is suspected, prompt collaboration with cardiologists is recommended. Our management strategy of care by a onco-cardiology team may contribute to the early diagnosis and treatment of myocarditis.

Association of cardiac troponin I level with in-hospital and late mortality in dialysis patients

Background

Cardiovascular diseases (CVDs) are highly prevalent among the end-stage renal disease (ESRD) patients. Prognostic value of cardiac troponin I (cTnI) in patients with asymptomatic ESRD is less conclusive. This study was an observational study to evaluate correlation of first admitted cTnI level with early and late (during 6 months) hospitalization and mortality of ESRD patient admitted due to non-acute coronary and non-heart failure causes in ESRD patients.

Materials and Methods

In this prospective observational study, 460 dialysis patients without overt CVD who were admitted at two university hospital were included and followed during 6 months. Patients' demographic information and laboratory investigations including cTnI level and cause of admission were recorded. The association between cTnI level with in-hospital and late mortality was evaluated.

Results

cTnI level was higher in female (35.9%), hemodialysis patients (28.1%), and patients with permanent catheter vascular access (29.4%). There were significant differences in level of triglyceride (TG), low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol between patients with normal and abnormal cTnI levels (P < 0.05). Patients with abnormal cTnI levels had higher level of TG and LDL cholesterol and lower level of HDL cholesterol. cTnI levels were associated with higher in-hospital and 6-month follow-up mortality rate. In logistic regression analysis, only female gender (odds ratio [OR] =1.89, confidence interval [CI] =1.22-3.076) and TG (OR = 1.007, CI = 1.003-1.01) were positively and HDL cholesterol level (OR = 0.994, CI = 0.98-0.99) was negatively associated with increased cTnI level. cTnI level was associated with early (OR = 4.81, CI = 1.64-14.89) and late (OR = 4.31, CI = 1.61-10.96) mortality.

Conclusion

Although in this study, cTnI level is not directly associated with cardiovascular disorders and admission and readmission causes, it is a strong predictor of early and late mortality.

Intradialytic cardiovascular injury is lowest in high-volume haemodiafiltration: a randomized cross-over trial in four intermittent dialysis strategies

Background

Intradialytic hypotension (IDH) and subsequent tissue damage may contribute to the poor outcome of chronic haemodialysis (HD) patients. While the IDH-incidence is lower in high-volume haemodiafiltration (HV-HDF) than in standard HD (S-HD), survival is better in HV-HDF. Tissue injury, as measured by extracellular vesicle (EV)-release, was compared between four modalities.

Methods

Forty chronic patients were cross-over randomized to S-HD, cool-HD (C-HD), low-volume HDF (LV-HDF), and HV-HDF. Blood pressure was recorded every 15 minutes. EVs from circulating blood-cell-elements (bio-incompatibility-related) and cardiovascular (CV) tissues (CV-related), were measured before and after dialysis. The influence of modalities and IDH on the rate of change of EVs was assessed. Both crude and haemoconcentration-adjusted analyses were performed.

Results

Leukocyte and erythrocyte-derived EVs increased in all modalities. Platelet-derived EVs increased more in LV-HDF and HV-HDF (68.4 respectively 56.1 × 106/ml) than in S-HD (27.5 × 106/ml), P values for interaction were <.01 respectively .06. Endothelial-derived CD144+ (2.3 × 106/ml in HV-HDF and 9.8 × 106/ml in S-HD) and cardiomyocyte-derived Connexin-43+ (12.0 respectively 31.9 × 106/ml) EVs increased less in HV-HDF than in S-HD (P for interaction .03 respectively .06). Correction for haemoconcentration attenuated all changes, although the increase in platelet-derived EVs remained significant in LV-HDF and HV-HDF, and CD144+ and Connexin-43+ EVs increased most in S-HD. EV release was similar in patients with varying IDH susceptibility and in sessions with and without IDH.

Conclusions

Most EVs increase during HD and HDF. Regarding platelet-derived EVs, HDF appears less biocompatible than HD. Considering CV-related EVs, tissue injury seems less pronounced in HV-HDF. The finding that EV release is IDH-independent needs confirmation.

Utility of Cardiac Troponins in Patients With Chronic Kidney Disease

Cardiovascular disease is a major cause of death worldwide especially in patients with chronic kidney disease (CKD). Troponin T and troponin I are cardiac biomarkers used not only to diagnose acute myocardial infarction (AMI) but also to prognosticate cardiovascular and all-cause mortality. The diagnosis of AMI in the CKD population is challenging because of their elevated troponins at baseline. The development of high-sensitivity cardiac troponins shortens the time needed to rule in and rule out AMI in patients with normal renal function. While the sensitivity of high-sensitivity cardiac troponins is preserved in the CKD population, the specificity of these tests is compromised. Hence, diagnosing AMI in CKD remains problematic even with the introduction of high-sensitivity assays. The prognostic significance of troponins did not differ whether it is detected with standard or high-sensitivity assays. The elevation of both troponin T and troponin I in CKD patients remains strongly correlated with adverse cardiovascular and all-cause mortality, and the prognosis becomes poorer with advanced CKD stages. Interestingly, the degree of troponin elevation appears to be predictive of the rate of renal decline via unclear mechanisms though activation of the renin-angiotensin and other hormonal/oxidative stress systems remain suspect. In this review, we present the latest evidence of the use of cardiac troponins in both the diagnosis of AMI and the prognosis of cardiovascular and all-cause mortality. We also suggest strategies to improve on the diagnostic capability of these troponins in the CKD/end-stage kidney disease population.

Elevated Cardiac Troponin I following Asymptomatic Intradialytic Hypotension: A Pilot Study with a 2-Year Follow-Up

Background

Intradialytic hypotension (IDH) has been recognized as a serious and frequent complication during hemodialysis (HD) of end-stage renal disease (ESRD) patients, but the effect of asymptomatic IDH on cardiac troponin I (cTnI) levels is not definitively elucidated.

Methods

70 asymptomatic HD patients with negative predialysis cTnI were included. They were on maintenance HD thrice weekly. All patients were monitored during the HD session for hemodynamic changes and symptoms related to IDH. Patients were followed for two years, and their outcomes are noted as an acute coronary syndrome (ACS), cardiac death, no ACS, noncardiac death, and kidney transplant.

Results

Compared with the baseline blood pressure values, there was a drop in systolic blood pressure for all subjects, but according to the 2007 European Best Practice Guidelines on hemodynamic instability, asymptomatic IDH was defined in 27 (38.6%) patients. The results demonstrated a significant correlation (r = 0.492) (p < 0.05) between asymptomatic IDH and elevated postdialysis levels of cTnI. In 2-year follow-up of patients, ACS and cardiac death happened more in patients with elevated cTnI.

Conclusion

The results of our study suggest that asymptomatic IDH affects cTnI levels. Given that cTnI is a marker of myocardial damage and a predictor of cardiovascular mortality in ESRD patients, these findings recommend that considering the asymptomatic decrease in blood pressure levels during HD is very important and critical.

Troponin Cut-Offs for Acute Myocardial Infarction in Patients with Impaired Renal Function—A Systematic Review and Meta-Analysis

Identifying acute myocardial infarction in patients with renal disease is notoriously difficult, due to atypical presentation and chronically elevated troponin. The aim of this study was to identify a specific troponin T/troponin I cut-off value for diagnosis of acute myocardial infarction in patients with renal impairment via meta-analysis. Two investigators screened 2590 publications from MEDLINE, Embase, PubMed, Web of Science, and the Cochrane library. Only studies that investigated alternative cut-offs according to renal impairment were included. Fifteen articles fulfilled the inclusion criteria. Six studies were combined for meta-analysis. The manufacturer’s upper reference level for troponin T is 14 ng/L. Based on the meta-analyses, cut-off values for troponin in patients with renal impairment with myocardial infarction was 42 ng/L for troponin I and 48 ng/L for troponin T. For patients on dialysis the troponin T cut-off is even higher at 239 ng/L. A troponin I cut-off value for dialysis patients could not be established due to lack of data. The 15 studies analyzed showed considerable diversity in study design, study population, and the definition of myocardial infarction. Further studies are needed to define a reliable troponin cut-off value for patients with kidney disease, especially in dialysis patients, and to allow necessary subanalysis.

Extracellular water/total body water ratio as predictor of mortality in hemodialysis patients

BACKGROUND

Overhydration is a predictor of mortality in hemodialysis (HD) patients. Bioimpedance spectroscopy (BIS) is used to determine the body composition. Extracellular Water/Total Body Water (ECW/TBW) ratio has been proposed to predict mortality.

METHODS

Multicenter, prospective, observational, proof-of-concept study to estimate the impact of ECW/TBW in global and cardiovascular mortality and the relationship with cardiovascular biomarkers. The study included 60 patients (mean age, 71.8 ± 11.4 years; mean time on HD, 52.3 ± 30.8 months) with a median follow-up of 30.5 months (IQ range, 17.2-34 months).

RESULTS

Post-dialysis ECW/TBW was directly associated with NT-proBNP and cTnT. During the study 28 patients died, most of them (43%) due to cardiovascular events. Compared to the survivors, these subjects had a higher post-dialysis ECW/TBW ratio (p = 0.006), while for cardiovascular mortality the only significant difference was a higher pre-dialysis ECW/TBW. The ability of post-dialysis ECW/TBW ratio to predict all-cause mortality had an area under the ROC curve (AUC) of 0.71 (CI 95%, 0.57-0.81; p = 0.002), with a cutoff point of 0.5023. For cardiovascular mortality the AUC was 0.66 (CI 95%, 0.52-0.77; p = 0.045), with a cutoff point of 0.4713.

CONCLUSIONS

The post-dialysis ECW/TBW ratio measured by BIS can be a predictor of all-cause and cardiovascular mortality.

Effect of low-flux and high-flux dialysis membrane on plasma concentrations of cardiac troponin I

Aim: Cardiac troponin I (cTnI) concentration stability during dialysis have not been fully elucidated. The aim is to evaluate the effect of a single dialysis session on plasma cTnI. Patients & methods: From 122 consecutive anuric adult patients (75 [61.5%] men, age 27-86 years, median 67) on chronic hemodialysis blood samples for cTnI measurement were taken before and after a dialysis. Results: Dialysis had no effect on high-flux membranes (geometric means ratio = 0.99, 0.94-1.05, df 119, t = -0.19, multiplicity adjusted p = 0.847), but cTnI levels were higher after dialysis in patients on low-flux membranes (geometric means ratio = 1.14, 1.02-1.27, df 119, t = 2.59, adjusted p = 0.021). Conclusion: Dialysis session using low-flux membranes might increase the plasma cTnI.

Variability of high-sensitivity cardiac troponin T and I in asymptomatic patients receiving hemodialysis

Variation of high-sensitivity cardiac troponin I and T (hs-cTn) during hemodialysis has been observed. Observational studies demonstrated the increased incidence of adverse cardiovascular events after long compared to short interdialytic intervals. Therefore, we aimed to compare variation of hs-cTnI and hs-cTnT before and after hemodialysis and between short and long interdialytic intervals. We enrolled 200 asymptomatic patients receiving regular hemodialysis. The hs-cTnI and hs-cTnT levels were measured before and after hemodialysis on the day after short and long interdialytic intervals. Mean age was 62.3 ± 14.8 years (Male 55.5%). Prevalence of increased hs-cTnI and hs-cTnT was 34.5% and 99.0%, respectively. The median ± interquartile range of hs-cTnT increased significantly after hemodialysis during short and long interdialytic intervals. However, hs-cTnI level did not increase after hemodialysis during short and long intervals. We found that levels of hs-cTnI and T did not differ between short interdialytic and long interdialytic intervals. We demonstrated higher prevalence of elevated hs-cTnT in patients with regular hemodialysis compared to hs-cTnI. The rise of hs-cTnT was observed immediately after hemodialysis but no significant change of hs-cTnI was noted. Accordingly, hs-cTnI may be preferable as a diagnostic marker in patients with suspected acute myocardial infarction than hs-cTnT.

Short- and long-term biological variation of cardiac troponin I in healthy individuals, and patients with end-stage renal failure requiring haemodialysis or cardiomyopathy

Objectives High-sensitivity (hs) cardiac troponin (cTn) assays can quantitate small fluctuations in cTn concentration. Determining biological variation allows calculation of reference change values (RCV), to define significant changes. We assessed the short- and long-term biological variation of cardiac troponin I (cTnI) in healthy individuals and patients with renal failure requiring haemodialysis or cardiomyopathy. Methods Plasma samples were collected hourly for 4 h and weekly for seven further weeks from 20 healthy individuals, 9 renal failure patients and 20 cardiomyopathy patients. Pre- and post-haemodialysis samples were collected weekly for 7 weeks. Samples were analysed using a hs-cTnI assay (Abbott Alinity ci-series). Within-subject biological variation (CVI), analytical variation (CVA) and between-subject biological variation (CVG) was used to calculate RCVs and index of individuality (II). Results For healthy individuals, CVI, CVA, CVG, RCV and II values were 8.8, 14.0, 43.1, 45.8% and 0.38 respectively for short-term, and 41.4, 14.0, 25.8, 121.0% and 1.69 for long-term. For renal failure patients, these were 2.6, 5.8, 50.5, 17.6% and 0.30 respectively for short-term, and 19.1, 5.8, 11.2, 55.2% and 1.78 for long-term. For cardiomyopathy patients, these were 4.2, 10.0, 65.9, 30.0% and 0.16 respectively for short-term, and 17.5, 10.0, 63.1, 55.8% and 0.32 for long-term. Mean cTnI concentration was lower post-haemodialysis (15.2 vs. 17.8 ng/L, p < 0.0001), with a 16.9% mean relative change. Conclusions The biological variation of cTnI is similar between end-stage renal failure and cardiomyopathy patients, but proportionately greater in well-selected healthy individuals with very low baseline cTnI concentrations.

Variability in Cardiac Biomarkers during Hemodialysis: A Prospective Cohort Study

BACKGROUND

The effect of hemodialysis on cardiac biomarkers is unclear. We sought to evaluate the degree and causes of intradialytic variability of high sensitivity troponin I (hs-TnI), galectin-3 (gal-3), and heart-type fatty acid binding protein (hFABP).

METHODS

hs-TnI, gal-3, and hFABP were prospectively measured pre-dialysis and post-dialysis for 1 week every month for 6 months in 178 prevalent adult hemodialysis patients at a single center in Hamilton, Canada. The degree of change from pre-dialysis to post-dialysis for each cardiac biomarker was estimated with multilevel linear regression models.

RESULTS

The median change in the concentration of hs-TnI during hemodialysis was -1 ng/L (interquartile range [IQR] -1 to 2 ng/L) while gal-3 and hFABP changed by -36.3 ng/mL (IQR -27.7 to -46.8 ng/mL) and -19.41 ng/mL (IQR -13.61 to -26.87 ng/mL), respectively. The median (IQR) percentage intradialytic changes for hs-TnI, gal-3, and hFABP were 2.6% (-4.4% to 12.5%), -59.8% (-54.7% to -64.8%) and -35.3% (-28.4% to -42.1%), respectively. Ultrafiltration was associated with an increase in concentration of hs-TnI, gal-3, and hFABP (mean 0.99 ng/L, 1.05 ng/mL, and 1.9 ng/mL per L ultrafiltration, respectively, P < 0.001). Both gal-3 and hFABP concentrations decreased in association with the volume of blood processed (P < 0.001) and with hemodialysis treatment time (P  = 0.02 and P  = 0.04) while hs-TnI concentration decreased only in association with hemodialysis treatment time (P  < 0.001).

CONCLUSIONS

Ultrafiltration volume and hemodialysis treatment time influenced hs-TnI, gal-3, and hFABP concentrations during hemodialysis and should be considered when interpreting their measurement.

High-Sensitivity Troponin for Suspected Acute Coronary Syndrome in Patients With Chronic Kidney Disease Versus Patients Without Chronic Kidney Disease

BACKGROUND

Heart disease is the leading cause of death in the United States. Patients with acute coronary syndrome (ACS) who have chronic kidney disease (CKD) have a twofold increase in mortality compared to patients with normal kidney function. Patients with CKD tend to have elevated baseline high-sensitivity cardiac troponin-T (hs-cTnT) levels. We studied patients with or without CKD to find out if a higher baseline hs-cTnT influenced the change in hs-cTnT (delta) when ruling in or ruling out ACS.

METHODS

Eighty-nine patients were included in this study (29 with CKD; 60 without CKD). Delta hs-cTnT was dichotomized based on those who had delta of ≥ 5, or < 5. We calculated the positive predictive values, negative predictive values, sensitivities and specificities. Shapiro-Wilk test and independent t-test were used for the continuous variables. Mann-Whitney U test was used to examine the variables between the two groups. Chi-square test was used to compare the categorical variables between the two groups.

RESULTS

The mean ages of patients with CKD and without CKD were 61.2 and 58.9 years, respectively (P = 0.508). We found that although there were differences in the sensitivities, specificities, positive predictive values and negative predictive values of delta hs-cTnT > 5 for ACS between the patients with CKD and without CKD, the differences were not statistically significant. Subgroup analysis showed that in patients with CKD, the positive predictive values and sensitivities of delta hs-cTnT > 5 for CAD requiring percutaneous coronary intervention (PCI) and stent were significantly higher compared to the patients without CKD (82.4% vs. 27.3%, and 82.4% vs. 40.0%, respectively) (P < 0.05).

CONCLUSIONS

In calculating delta hs-cTnT to rule in or rule out ACS, the presence of CKD does not influence the delta. Patients with CKD and a delta hs-cTnT > 5 have significantly higher risk of undergoing PCI.

Chronic elevation of cardiac troponin I predicts the extent of coronary disease in hemodialysis patients presenting with acute enzyme elevation

Introduction

Elevation of cardiac troponin I (cTn-I) is associated with coronary artery disease (CAD) in asymptomatic patients with end-stage renal disease (ESRD) receiving hemodialysis. We aim to investigate the diagnostic value of chronically elevated cTn-I in ESRD patients presenting with an acute rise in serum cTn-I levels.

Methods

We performed a retrospective analysis of 364 patients. Using coronary angiography, we correlated baseline elevation of cTn-I with the severity of CAD when hemodialysis patients present with acute symptomatic elevation in serum cTn-I.

Results

In hemodialysis patients presenting with a rise in serum cTn-I above baseline levels, 59% had severe CAD, and 17% had no angiographic evidence of CAD. Hemodialysis patients with severe CAD had significantly higher baseline cTn-I levels compared to patients with non-severe CAD or normal coronaries (p < 0.0001). Baseline elevation of cTn-I in the severe CAD group was correlated with the degree of CAD occlusion (r2 0.56, p < 0.0001), fitting a positive linear model. Furthermore, baseline cTn-I differentiates between patients with and without severe CAD with a test accuracy of 0.72 (95% CI, 0.69-0.75, p < 0.001). At a value of ≥0.2 ng/mL (cutoff for myocardial necrosis), the specificity of baseline cTn-I for underlying severe CAD was 0.95.

Conclusions

Elevated baseline cTn-I has good accuracy for anticipating more advanced angiographic CAD when hemodialysis patients present with a symptomatic rise in serum cTn-I above baseline levels. Baseline elevation of cTn-I can be used for cardiac disease risk management in hemodialysis patients presenting with symptoms suggestive of CAD.

Value of the high-sensitivity troponin T assay for diagnosis of acute myocardial infarction in patients with and without renal insufficiency

BACKGROUND

Cardiac troponins are important markers for diagnosis of acute myocardial infarction (AMI) in general population; however, chronically-elevated troponins levels are often seen in patients with renal insufficiency, which reduce their diagnostic accuracy. The aim of our study was to access the diagnostic values of initial high-sensitive cardiac troponin T (hs-cTnT) and relative change of hs-cTnT for AMI in patients with and without renal insufficiency.

METHODS

Cardiac care unit patients with elevated hs-cTnT levels in 2017-2018 were enrolled. Receiver operating characteristic (ROC) curves were used to evaluate initial hs-cTnT levels and relative changes after 3 h of enrollment for diagnosis of AMI in patients with estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m² (low), and eGFR ≥ 60 mL/min/1.73 m² (normal).

RESULTS

Of 359 patients, 240 patients had low eGFR, and 119 patients had normal eGFR. The area under the ROC curve (AUC) for the initial hs-cTnT levels was 0.58 (95% CI, 0.5-0.65, p = 0.053) among patients with low eGFR and 0.54 (95% CI, 0.4-0.67, p = 0.612) among patients with normal eGFR. AUCs for relative changes of hs-cTnT were 0.82 (95% CI, 0.76-0.88, p < 0.001) in patients with low eGFR and 0.82 (95% CI, 0.71-0.91, p < 0.001) in patients with normal eGFR. Optimal cutoff values for the relative changes in hs-cTnT were 16% and 12% in patients with low eGFR and normal eGFR, respectively.

CONCLUSIONS

Relative changes in hs-cTnT levels had better diagnostic accuracy than initial hs-cTnT levels.

High-sensitivity troponin in chronic kidney disease: Considerations in myocardial infarction and beyond

Acute myocardial infarction (MI) represents one of the most common hospital encounters, with significant short-term and long-term morbidity and mortality, and frequently occurs in patients with chronic kidney disease (CKD). Cardiac troponin is an exquisitely sensitive biomarker for myocardial injury and plays an essential role in the diagnosis, risk-stratification, and management of MI. In 2017, the United States Food and Drug Administration approved Roche Diagnostics' 5th generation high-sensitivity cardiac troponin (hs-cTn) for clinical use. Whilst the improved analytical sensitivity of these new high-sensitivity troponin assays facilitate early diagnosis of MI, it also frequently identifies troponin elevations above the conventional reference threshold in the context of non-coronary conditions such as renal dysfunction, and can represent a major diagnostic challenge to clinicians. Furthermore, the optimal management strategy of patients with troponin elevation and high comorbidity burden, a common issue in patients with CKD, remains undefined. In recent years, there has been substantial research and progress undertaken in this rapidly evolving area. In this review, we aim to provide clinicians with an overview of hs-cTn in the setting of CKD as well as an update on its application and the particular considerations involved in the management of myocardial infarction, stable coronary artery disease and myocardial injury in this high risk population.