Yonsei Med J.  2009 Aug;50(4):537-545. 10.3349/ymj.2009.50.4.537.

Impact of Renal Dysfunction on Clinical Outcomes of Acute Coronary Syndrome

• Kang YU
• Jeong MH
• Kim SW

• KMID: 1758614
• DOI: http://doi.org/10.3349/ymj.2009.50.4.537

Abstract

PURPOSE
The present study aimed to compare the clinical outcomes and to investigate prognostic factors of acute coronary syndrome (ACS) in patients with renal dysfunction (RD). MATERIALS AND METHODS: The study was a retrospective cohort of 648 adult patients admitted with ACS between October 2005 and December 2006. The estimated glomerular filtration rate (GFR) was classified into 4 levels: 1) normal, GFR greater than 90 mL/min/1.73 m2; 2) mild RD, GFR of 60 to 90 mL/min/1.73 m2; 3) moderate RD, GFR of 30 to 60 mL/min/1.73 m2; and 4) severe RD, GFR less than 30 mL/min/1.73 m2. Primary end points were death and complication in hospital courses. Secondary end points were major adverse cardiac event (MACE) during follow-up. RESULTS: The median follow-up was 505 +/- 183 days, the mean age was 63 +/- 12 years, and 71.8 percent of the group were men. A graded association was observed between severity of RD and clinical outcomes. Severe RD independently predicted MACE [hazard ratio, 2.731; 95% confidence interval (CI), 1.058 to 7.047, p = 0.038]. Low hemoglobin level was also an independent risk factor for MACE (hazard ratio, 1.155; 95% CI, 1.020 to 1.307, p = 0.022). Use of lipid-lowering therapy (hazard ratio, 0.456; 95% CI, 0.242 to 0.857, p = 0.015) was associated with reduced risk for MACE. CONCLUSION: Severe RD and low hemoglobin level were an independent risk factors for the mortality and complications of ACS, while lipid-lowering therapy was associated with reduced risk.

Keyword

Acute coronary syndrome; glomerular filtration rate; risk factors

MeSH Terms

Acute Coronary Syndrome/*pathology
Aged
Coronary Angiography
Female
Glomerular Filtration Rate/physiology
Humans
Kidney Diseases/*physiopathology
Kidney Function Tests
Male
Middle Aged
Proportional Hazards Models
Retrospective Studies
Risk Factors

Figure

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  Fig. 1 Kaplan-Meier survival in patients with acute coronary syndrome according to renal function during follow-up. Severe renal dysfunction group showed lower probability of event-free survival than the other groups.

Reference

1. Sarnak MJ, Levey AS, Schoolwerth AC, Coresh J, Culleton B, Hamm LL, et al. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Hypertension. 2003. 42:1050–1065.

2. Tonelli M, Wiebe N, Culleton B, House A, Rabbat C, Fok M, et al. Chronic kidney disease and mortality risk: a systematic review. J Am Soc Nephrol. 2006. 17:2034–2047.

3. Muntner P, He J, Hamm L, Loria C, Whelton PK. Renal insufficiency and subsequent death resulting from cardiovascular disease in the United States. J Am Soc Nephrol. 2002. 13:745–753.

4. Manjunath G, Tighiouart H, Ibrahim H, MacLeod B, Salem DN, Griffith JL, et al. Level of kidney function as a risk factor for atherosclerotic cardiovascular outcomes in the community. J Am Coll Cardiol. 2003. 41:47–55.

5. Anavekar NS, McMurray JJ, Velazquez EJ, Solomon SD, Kober L, Rouleau JL, et al. Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction. N Engl J Med. 2004. 351:1285–1295.

6. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004. 351:1296–1305.

7. Weiner DE, Tighiouart H, Amin MG, Stark PC, MacLeod B, Griffith JL, et al. Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: a pooled analysis of community-based studies. J Am Soc Nephrol. 2004. 15:1307–1315.

8. Ahn SJ, Choi EJ. Renal Replacement Therapy in Korea: Insan Memorial Registry 1997. Korean J Nephrol. 1999. 18:1–15.

9. Shlipak MG, Heidenreich PA, Noguchi H, Chertow GM, Browner WS, McClellan MB. Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients. Ann Intern Med. 2002. 137:555–562.

10. Wright RS, Reeder GS, Herzog CA, Albright RC, Williams BA, Dvorak DL, et al. Acute myocardial infarction and renal dysfunction: a high-risk combination. Ann Intern Med. 2002. 137:563–570.

11. Beattie JN, Soman SS, Sandberg KR, Yee J, Borzak S, Garg M, et al. Determinants of mortality after myocardial infarction in patients with advanced renal dysfunction. Am J Kidney Dis. 2001. 37:1191–1200.

12. Coca SG, Krumholz HM, Garg AX, Parikh CR. Underrepresentation of renal disease in randomized controlled trials of cardiovascular disease. JAMA. 2006. 296:1377–1384.

13. Panetta CJ, Herzog CA, Henry TD. Acute coronary syndromes in patients with renal disease: what are the issues? Curr Cardiol Rep. 2006. 8:296–300.

14. Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendriksen S, et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med. 2006. 145:247–254.

15. Roberts WL, Moulton L, Law TC, Farrow G, Cooper-Anderson M, Savory J, et al. Evaluation of nine automated high-sensitivity C-reactive protein methods: implications for clinical and epidemiological applications: Part 2. Clin Chem. 2001. 47:418–425.

16. Prontera C, Emdin M, Zucchelli GC, Ripoli A, Passino C, Clerico A. Analytical performance and diagnostic accuracy of a fully-automated electrochemiluminescent assay for the N-terminal fragment of the pro-peptide of brain natriuretic peptide in patients with cardiomyopathy: comparison with immunoradiometric assay methods for brain natriuretic peptide and atrial natriuretic peptide. Clin Chem Lab Med. 2004. 42:37–44.

17. Ryan TJ, Faxon DP, Gunnar RM, Kennedy JW, King SB 3rd, Loop FD, et al. Guidelines for percutaneous transluminal coronary angioplasty. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty). Circulation. 1988. 78:486–502.

18. van Domburg RT, Hoeks SE, Welten GM, Chonchol M, Elhendy A, Poldermans D. Renal insufficiency and mortality in patients with known or suspected coronary artery disease. J Am Soc Nephrol. 2008. 19:158–163.

19. Walsh CR, O'Donnell CJ, Camargo CA Jr, Giugliano RP, Lloyd-Jones DM. Elevated serum creatinine is associated with 1-year mortality after acute myocardial infarction. Am Heart J. 2002. 144:1003–1011.

20. Al Suwaidi J, Reddan DN, Williams K, Pieper KS, Harrington RA, Califf RM, et al. Prognostic implications of abnormalities in renal function in patients with acute coronary syndromes. Circulation. 2002. 106:974–980.

21. Shlipak MG, Fried LF, Cushman M, Manolio TA, Peterson D, Stehman-Breen C, et al. Cardiovascular mortality risk in chronic kidney disease: comparison of traditional and novel risk factors. JAMA. 2005. 293:1737–1745.

22. Schiffrin EL, Lipman ML, Mann JF. Chronic kidney disease: effects on the cardiovascular system. Circulation. 2007. 116:85–97.

23. DeFilippi C, van Kimmenade RR, Pinto YM. Amino-terminal pro-B-type natriuretic peptide testing in renal disease. Am J Cardiol. 2008. 101:82–88.

24. Kalantar-Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD. Malnutrition-inflammation complex syndrome in dialysis patients: causes and consequences. Am J Kidney Dis. 2003. 42:864–881.

25. Qureshi AR, Alvestrand A, Danielsson A, Divino-Filho JC, Gutierrez A, Lindholm B, et al. Factors predicting malnutrition in hemodialysis patients: a cross-sectional study. Kidney Int. 1998. 53:773–782.

26. Kaysen GA, Eiserich JP. The role of oxidative stress-altered lipoprotein structure and function and microinflammation on cardiovascular risk in patients with minor renal dysfunction. J Am Soc Nephrol. 2004. 15:538–548.

27. Pecoits-Filho R, Heimbürger O, Bárány P, Suliman M, Fehrman-Ekholm I, Lindholm B, et al. Associations between circulating inflammatory markers and residual renal function in CRF patients. Am J Kidney Dis. 2003. 41:1212–1218.

28. Ross R. Atherosclerosis--an inflammatory disease. N Engl J Med. 1999. 340:115–126.

29. Menon V, Greene T, Wang X, Pereira AA, Marcovina SM, Beck GJ, et al. C-reactive protein and albumin as predictors of all-cause and cardiovascular mortality in chronic kidney disease. Kidney Int. 2005. 68:766–772.

30. Culleton BF, Larson MG, Wilson PW, Evans JC, Parfrey PS, Levy D. Cardiovascular disease and mortality in a community-based cohort with mild renal insufficiency. Kidney Int. 1999. 56:2214–2219.

31. Walker AM, Schneider G, Yeaw J, Nordstrom B, Robbins S, Pettitt D. Anemia as a predictor of cardiovascular events in patients with elevated serum creatinine. J Am Soc Nephrol. 2006. 17:2293–2298.

32. Keough-Ryan TM, Kiberd BA, Dipchand CS, Cox JL, Rose CL, Thompson KJ, et al. Outcomes of acute coronary syndrome in a large Canadian cohort: impact of chronic renal insufficiency, cardiac interventions, and anemia. Am J Kidney Dis. 2005. 46:845–855.

33. Levin A, Thompson CR, Ethier J, Carlisle EJ, Tobe S, Mendelssohn D, et al. Left ventricular mass index increase in early renal disease: impact of decline in hemoglobin. Am J Kidney Dis. 1999. 34:125–134.

34. Grune T, Sommerburg O, Siems WG. Oxidative stress in anemia. Clin Nephrol. 2000. 53:S18–S22.

35. Silverberg DS, Wexler D, Blum M, Tchebiner JZ, Sheps D, Keren G, et al. The effect of correction of anaemia in diabetics and non-diabetics with severe resistant congestive heart failure and chronic renal failure by subcutaneous erythropoietin and intravenous iron. Nephrol Dial Transplant. 2003. 18:141–146.

36. Lonn E, Grewal J. Drug therapies in the secondary prevention of cardiovascular diseases: Successes, shortcomings and future directions. Curr Vasc Pharmacol. 2006. 4:253–268.

37. Hyre AD, Fox CS, Astor BC, Cohen AJ, Muntner P. The impact of reclassifying moderate CKD as a coronary heart disease risk equivalent on the number of US adults recommended lipid-lowering treatment. Am J Kidney Dis. 2007. 49:37–45.

38. Nissen SE, Tuzcu EM, Schoenhagen P, Crowe T, Sasiela WJ, Tsai J, et al. Statin therapy, LDL cholesterol, C-reactive protein, and coronary artery disease. N Engl J Med. 2005. 352:29–38.