Impaired renal function predicts short term prognosis in patients with acute pulmonary embolism

Transcription

1 Impaired renal function predicts short term prognosis in patients with acute pulmonary embolism Kostrubiec Maciej, Łabyk Andrzej, Pedowska-Włoszek Jusyna, Pacho Szymon, Jankowski Krzysztof, Koczaj-Bremer Magdalena, Dul Paweł, Wojciechowski Artur, Pruszczyk Piotr The Medical University of Warsaw, Poland

2 Introduction Torbicki et al. EHJ 2008

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4 Introduction Glomerular filtration rate (GFR) is one of the generally accepted indicators of increased mortality in various cardiovascular diseases like: acute coronary syndromes (included into the GRACE risk scale) heart failure Al Suwaidi J et al. Circulation 2002; 106: Gibson CM et al. J Am Coll Cardiol 2003; 42: Granger CB et al. Arch Intern Med 2003; 163: Damman K eta al. J Card Fail 2007; 13:

5 Introduction ICOPER registry - creatinine concentration> 177 umol/l predicted 3-month mortality [1] Renal insufficiency (creatinine >2 mg/dl) predicted death within 7 days with an odds ratio (OR) of 2.66 in univariate analysis (in the multivariatemodel p=0.07) [2] Renal failure predicted 40-day all-casue moratlity HR % (CI: p=0.002) in univariate analysis [3] RIETE registry of the (5.7%) pts with VTE had a Cr clearance <30 ml/min during the 3-month observation - increased incidence of fatal bleeding, fatal PE and all-cause death [4] 1) Goldhaber SZ et al. Lancet 1999; 353: ) Conget F et al. Thromb Haemost 2008; 100: ) Kostrubiec M et al. Eur Heart J 2005; 26: ) Falga C et al. Thromb Haemost 2007; 98:

6 Hypothesis Renal dysfunction is an independent marker of early mortality in APE And renal function assessment may improve troponin-based risk stratification

7 Methods Inclusion criteria: age > 18 yrs acute pulmonary embolism (APE) - proven by spiral CT End point: 30-day all-cause mortality

8 Methods On admission blood samples were obtained for: creatinine ctnt (Roche, ECLIA) and ctni (Dimension RxL, Dade Behring) GFR was estimated using the Modification of Diet in Renal Disease (MDRD) formula. GFR= 186 (Scr)1.154 Age)0.203 (0.742 if female) (1.210 if African-American) where serum creatinine (Scr) is measured in milligram per deciliter and age in years

9 Material 220 consecutive pts with APE (86M, 134F) mean age 64±18 yrs

10 Clinical characteristic 8 pts with high-risk PE 131 pts with moderate-risk PE 81 pts with low-risk PE 212 pts

11 Clinical outcome 23 (10%) of pts died by 30th day of observation 17 (8%) APE-related deaths (clinically diagnosed irreversible RV insufficiency or recurrent PE) 4 deaths in the high-risk APE (all cause/ape mortality 50%/50%) 18 fatal cases in moderate-risk PE (14%/11%) 1 death in low-risk APE (1%/1%)

12 Results Impaired renal function in 47% pts with APE (GFR <60 ml/min)

13 Results Glomerular filtration rate (GFR) values in non-survivors and survivors

14 Results ROC curve of GFR for predicting 30-day mortality in all APE pts GFR<35 ml/min GFR<35ml/min was in 32 (15%) pts sensitivity 52%, specificity 90%, PPV 38% NPV 94% for prediction of death within 30 days after admission In pts with GFR<35ml/min: 10 APE-related deaths and 2 deaths related to major bleeding; however, both patients with fatal hemorrhage had elevated ctn and echocardiographic signs of RV dysfunction

15 Results Comparison of ROC curves for GFR and ctn in pts with non-high-risk APE

16 Results Cumulative 30-day survival (Kaplan Meier) of 212 pts with non-high-risk APE, according to GFR and troponin independent mortality predictors for 30-day allcause mortality: GFR (HR 1.46, CI95%: , per 10 ml/min decrease, p<0.01), positive troponin (HR 14.1, CI95%: ; p=0.02), increased heart rate (HR 1.31, CI95%: ; per 10 beats, p<0.01) history of CHF (HR 4.9, CI95%: ; p=0.001)

17 Conclusion Impaired kidney function, present in 47% of APE patients, is related to all-cause mortality. In initially normotensive patients, a GFR<35mL/min predicts 30-day mortality. Moreover, GFR assessment can improve troponin-based risk stratification of APE.

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19 Acute Pulmonary Embolism Acute or Chronic Kidney Dysfunction?

20 N-GAL, marker of acute kidney injury, in patients with APE p< (48-200) N-GAL [ng/ml] (15-199) 56(7-200) low risk moderate risk high risk Mediana 25%-75% Min-Maks N-GAL [ng/ml] p< (39-200) 60 55(7-200) N-GAL>75ng/ml in 30% of pts survivors non-survivors Mediana 25%-75% Min-Maks