Acute decline in renal function, inflammation, and cardiovascular risk after an acute coronary syndrome.

BACKGROUND AND OBJECTIVES Chronic kidney disease is associated with a higher risk of cardiovascular outcomes. The prognostic significance of worsening renal function has also been shown in various cohorts of cardiac disease; however, the predictors of worsening renal function and the contribution of inflammation remains to be established. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Worsening renal function was defined as a 25% or more decrease in estimated GFR (eGFR) over a 1-mo period in patients after a non-ST or ST elevation acute coronary syndromes participating in the Aggrastat-to-Zocor Trial; this occurred in 5% of the 3795 participants. RESULTS A baseline C-reactive protein (CRP) in the fourth quartile was a significant predictor of developing worsening renal function (odds ratio, 2.48; 95% confidence interval, 1.49, 4.14). After adjusting for baseline CRP and eGFR, worsening renal function remained a strong multivariate predictor for the combined cardiovascular composite of CV death, recurrent myocardial infarction (MI), heart failure or stroke (hazard ratio, 1.6; 95% confidence interval, 1.1, 2.3). CONCLUSIONS Patients with an early decline in renal function after an acute coronary syndrome are at a significant increased risk for recurrent cardiovascular events. CRP is an independent predictor for subsequent decline in renal function and reinforces the idea that inflammation may be related to the pathophysiology of progressive renal disease.

[1]  J. Schold,et al.  Acute Kidney Injury Is Associated With Increased Long-Term Mortality After Cardiothoracic Surgery , 2009, Circulation.

[2]  C. O'connor,et al.  Incidence, predictors at admission, and impact of worsening renal function among patients hospitalized with heart failure. , 2004, Journal of the American College of Cardiology.

[3]  S. Solomon,et al.  Increase in creatinine and cardiovascular risk in patients with systolic dysfunction after myocardial infarction. , 2006, Journal of the American Society of Nephrology : JASN.

[4]  R. Gans,et al.  C-reactive protein is associated with renal function abnormalities in a non-diabetic population. , 2003, Kidney international.

[5]  A. Go,et al.  Hemoglobin Level, Chronic Kidney Disease, and the Risks of Death and Hospitalization in Adults With Chronic Heart Failure: The Anemia in Chronic Heart Failure: Outcomes and Resource Utilization (ANCHOR) Study , 2006, Circulation.

[6]  Robert M Califf,et al.  Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction. , 2004, The New England journal of medicine.

[7]  Tom Greene,et al.  Assessing kidney function--measured and estimated glomerular filtration rate. , 2006, The New England journal of medicine.

[8]  Hans L. Hillege,et al.  Renal Function as a Predictor of Outcome in a Broad Spectrum of Patients With Heart Failure , 2006, Circulation.

[9]  M. Pfeffer,et al.  Early intensive vs a delayed conservative simvastatin strategy in patients with acute coronary syndromes: phase Z of the A to Z trial. , 2004, JAMA.

[10]  Ethan M Balk,et al.  K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. , 2002, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[11]  H. Tsutsui [Candesartan in heart failure: assessment of reduction in mortality and morbidity]. , 2007, Nihon rinsho. Japanese journal of clinical medicine.

[12]  R. Califf,et al.  Prognostic value of serial B-type natriuretic peptide testing during follow-up of patients with unstable coronary artery disease. , 2005, JAMA.

[13]  Sean M. O'Brien,et al.  Impact of Renal Dysfunction on Outcomes of Coronary Artery Bypass Surgery: Results From the Society of Thoracic Surgeons National Adult Cardiac Database , 2006, Circulation.

[14]  G. Eknoyan,et al.  National Kidney Foundation Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification , 2003, Annals of Internal Medicine.

[15]  H. Krumholz,et al.  Correlates and impact on outcomes of worsening renal function in patients > or =65 years of age with heart failure. , 2000, The American journal of cardiology.

[16]  M. Pfeffer,et al.  Proteinuria, impaired kidney function, and adverse outcomes in people with coronary disease: analysis of a previously conducted randomised trial , 2006, BMJ : British Medical Journal.

[17]  E. Antman,et al.  Association of glomerular filtration rate on presentation with subsequent mortality in non-ST-segment elevation acute coronary syndrome; observations in 13,307 patients in five TIMI trials. , 2004, European heart journal.

[18]  M. Pfeffer,et al.  Estimated glomerular filtration rate, inflammation, and cardiovascular events after an acute coronary syndrome. , 2008, American heart journal.

[19]  R. Califf,et al.  The A-to-Z Trial: Methods and rationale for a single trial investigating combined use of low-molecular-weight heparin with the glycoprotein IIb/IIIa inhibitor tirofiban and defining the efficacy of early aggressive simvastatin therapy. , 2001, American heart journal.

[20]  S. Solomon,et al.  Chronic Kidney Disease, Cardiovascular Risk, and Response to Angiotensin-Converting Enzyme Inhibition After Myocardial Infarction: The Survival And Ventricular Enlargement (SAVE) Study , 2004, Circulation.

[21]  L. Bachmann,et al.  Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. , 2004, Journal of the American Society of Nephrology : JASN.

[22]  H. Krumholz,et al.  Long-term prognosis of acute kidney injury after acute myocardial infarction. , 2008, Archives of internal medicine.

[23]  N. Sinzobahamvya,et al.  Pediatric cardiorenal syndrome: a new name for an old problem? , 2008, Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

[24]  J. Towbin,et al.  Worsening renal function in children hospitalized with decompensated heart failure: Evidence for a pediatric cardiorenal syndrome?* , 2008, Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

[25]  C. O'connor,et al.  The prognostic importance of different definitions of worsening renal function in congestive heart failure. , 2002, Journal of cardiac failure.

[26]  M. Tonelli,et al.  The association among renal insufficiency, pharmacotherapy, and outcomes in 6,427 patients with heart failure and coronary artery disease. , 2004, Journal of the American College of Cardiology.

[27]  Gary S Francis,et al.  Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. , 2009, Journal of the American College of Cardiology.

[28]  R. Califf,et al.  Admission or Changes in Renal Function During Hospitalization for Worsening Heart Failure Predict Postdischarge Survival: Results From the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) , 2008, Circulation. Heart failure.

[29]  M. Jessup,et al.  The cardiorenal syndrome: do we need a change of strategy or a change of tactics? , 2009, Journal of the American College of Cardiology.

[30]  R. Bellomo,et al.  Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group , 2004, Critical care.