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
Introduction Torbicki et al. EHJ 2008
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: 974 80. Gibson CM et al. J Am Coll Cardiol 2003; 42: 1535 43. Granger CB et al. Arch Intern Med 2003; 163: 2345 53. Damman K eta al. J Card Fail 2007; 13: 599 608.
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 6.43 95% (CI:2.22 18.61 p=0.002) in univariate analysis [3] RIETE registry - 1037 of the 18 251 (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: 1386 9 2) Conget F et al. Thromb Haemost 2008; 100: 937 42 3) Kostrubiec M et al. Eur Heart J 2005; 26: 2166 72 4) Falga C et al. Thromb Haemost 2007; 98: 771 6.
Hypothesis Renal dysfunction is an independent marker of early mortality in APE And renal function assessment may improve troponin-based risk stratification
Methods Inclusion criteria: age > 18 yrs acute pulmonary embolism (APE) - proven by spiral CT End point: 30-day all-cause mortality
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
Material 220 consecutive pts with APE (86M, 134F) mean age 64±18 yrs
Clinical characteristic 8 pts with high-risk PE 131 pts with moderate-risk PE 81 pts with low-risk PE 212 pts
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%)
Results Impaired renal function in 47% pts with APE (GFR <60 ml/min)
Results Glomerular filtration rate (GFR) values in non-survivors and survivors
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
Results Comparison of ROC curves for GFR and ctn in pts with non-high-risk APE
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%:1.11 1.92, per 10 ml/min decrease, p<0.01), positive troponin (HR 14.1, CI95%:1.4 37.6; p=0.02), increased heart rate (HR 1.31, CI95%:1.07 1.61; per 10 beats, p<0.01) history of CHF (HR 4.9, CI95%:1.9 12.4; p=0.001)
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.
Acute Pulmonary Embolism Acute or Chronic Kidney Dysfunction?
N-GAL, marker of acute kidney injury, in patients with APE 220 200 180 p<0.05 160 140 78(48-200) N-GAL [ng/ml] 120 100 80 60 40 20 0-20 53(15-199) 56(7-200) low risk moderate risk high risk Mediana 25%-75% Min-Maks N-GAL [ng/ml] 220 200 180 160 140 120 100 80 p<0.02 86(39-200) 60 55(7-200) N-GAL>75ng/ml in 30% of pts 40 20 0-20 survivors non-survivors Mediana 25%-75% Min-Maks