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ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 4  |  Page : 1222-1227

Prognostic value of renal function in patients with acute coronary syndrome


Department of Cardiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission11-Feb-2021
Date of Decision25-Jun-2021
Date of Acceptance28-Jun-2021
Date of Web Publication24-Dec-2021

Correspondence Address:
Asmaa E Al-Beltagy
MBBCh, Elmahala Elkobra, Gharbia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_40_21

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  Abstract 


Background
Worsening renal function has been shown to be associated with poor outcomes in patients with acute coronary syndrome (ACS).
Objective
To assess the prognostic value of renal function test in patients with ACS.
Patients and methods
This cross-sectional observational study included 100 patients with ACS. Serum creatinine levels were measured on admission, after 48 h and at the time of discharge. Patients were divided according to the change in serum creatinine into three groups: group I (69 patients), with serum creatinine change less than 0.3 mg/dl; group II (15 patients), with a decrease in serum creatinine more than or equal to 0.3 mg/dl; group III (16 patients), with an increase in serum creatinine more than or equal to 0.3 mg/dl. The relationship between serum creatinine and in-hospital outcomes, complications, and mortality was evaluated.
Results
The prevalence of diabetes was significantly higher in group III compared with other groups (P < 0.05). Patients in group III had significantly lower ejection fraction (P < 0.001). In-hospital mortality was 13% in group I, 6.7% in group II, and 81.2% in group III (P < 0.001). Acute pulmonary edema, cardiogenic shock, and the need for mechanical ventilation were more prevalent significantly in group III. The cutoff point of peak serum creatinine more than 2.3 mg/dl during admission had 93.3% sensitivity and 97.7% specificity in predicting in-hospital mortality.
Conclusion
In ACS patients, daily serum creatinine level and its change patterns are strong predictors of in-hospital complications and mortality. Renal function test has a good prognostic value in identifying high-risk patients.

Keywords: acute coronary syndrome, in-hospital outcome, serum creatinine


How to cite this article:
Ibrahim WA, Al-Beltagy AE, Abd Al-Khalek MY. Prognostic value of renal function in patients with acute coronary syndrome. Menoufia Med J 2021;34:1222-7

How to cite this URL:
Ibrahim WA, Al-Beltagy AE, Abd Al-Khalek MY. Prognostic value of renal function in patients with acute coronary syndrome. Menoufia Med J [serial online] 2021 [cited 2022 Jan 27];34:1222-7. Available from: http://www.mmj.eg.net/text.asp?2021/34/4/1222/333251




  Introduction Top


Serum creatinine levels measured at hospital presentation have been shown to have prognostic value in acute coronary syndromes (ACS) [1],[2]. The factors that could initiate acute kidney injury during hospitalization of ACS patients include old age, hypotension, shock, heart failure, uncontrolled diabetes mellitus, and use of contrast during primary percutaneous intervention (PCI) [3]. Chronic heart and kidney disease are associated with frequent hospitalization and increased mortality. A sizable myocardial infarction results in negative changes to renal structure and function and the renal response to a myocardial infarction is a predictor of the patient's future health. Markers of kidney function at the time of the heart attack correlate with the patient's clinical condition [4].

Patients who show a decrease of serum creatinine during hospitalization, and this reflecting hemodynamic stabilization, have a favorable prognosis in comparison with patients who demonstrated worsening of renal function.

The aim of this study was to determine whether daily serum creatinine evaluation and its change pattern could better reflect in-hospital mortality than the initial serum creatinine value only and provide a more accurate and dynamic prognostic evaluation of ACS patients.


  Patients and methods Top


This cross-sectional observational study was conducted on 100 patients admitted to Mahalla Cardiac Center and Menoufia University Hospital with ACS in the period from January 2019 to October 2020. All patients were enrolled in the study after obtaining their written informed consent and approval of the local ethical committee of the hospital. Patients on artificial renal dialysis, those who had significant valvular heart disease, pregnancy, and malignancy were excluded from the study.

ST segment elevation myocardial infarction (STEMI) was diagnosed by new ST elevation at the J point in two contiguous leads with the cut point: more than or equal to 1 mm in all leads other than leads V2–V3 where the following cut points apply: more than or equal to 2 mm in men more than or equal to 40 years, more than or equal to 2.5 mm in men less than 40 years, or more than or equal to 1.5 mm in women, regardless of age. Non-STEMI (NSTEMI) was defined by elevated cardiac enzymes without persistent ST elevation or with ST depression. Unstable angina was defined by the presence of acute chest pain but no persistent ST-segment elevation and negative cardiac enzymes.

All study populations were examined by transthoracic echocardiography using Vivid 9, General Electric Healthcare (GE Vingmed, Strandpromenaden 45 Horten, 3183 Norway) equipped with harmonic M5S variable-frequency (1.7–4 MHz) phased-array transducer. The echocardiographic examination included the standard views: long-axis parasternal, apical 4, 5, and 2-chamber views. All patients underwent conventional M-mode and two-dimensional echocardiographic examination. Two-dimensional echocardiography was done to detect overall ventricular performance, regional wall motion, and sizes of different heart chambers. Ejection fraction (EF) of the left ventricle was estimated by identifying end-diastolic and end-systolic left-ventricular diameters in M-mode echocardiography and by Simpson's formula [5].

Measurement of serum creatinine level: Serum creatinine was measured at the time of admission, after 48 h, and at discharge.

Patients had been divided into three groups according to the change of serum creatinine during hospital stay:

Group I: stable renal function (SRF) with serum creatinine change less than 0.3 mg/dl.

Group II: improved renal function (IRF) with a decrease in serum creatinine more than or equal to 0.3 mg/dl.

Group III: worsening renal function (WRF) with an increase in serum creatinine more than or equal to 0.3 mg/dl

Primary PCI was done for STEMI patients, immediate invasive strategy (within 2 h) was applied to very-high-risk NSTMI patients, and early invasive strategy was applied to high-risk patients (within 24 h), while invasive PCI within 72 h was applied to intermediate-risk NSTEMI patients [6].

All patients had been followed up during hospital stay for development of complications, such as cardiogenic shock, pulmonary edema, serious arrhythmias, or death.

Statistical analysis of the data

Data were fed to the computer and analyzed using IBM SPSS software package, version 20.0. (IBM Corp., Armonk, New York, USA). Qualitative data were described using number and percent. The Kolmogorov–Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, and SD. Significance of the obtained results was judged at the 5% level.

The used tests were χ2 test: for categorical variables, to compare between different groups. Fisher's exact test or Monte Carlo correction: correction for χ2 when more than 20% of the cells have an expected count less than 5. Student t test: for normally distributed quantitative variables, to compare between two studied groups. F test (analysis of variance): for normally distributed quantitative variables, to compare between more than two groups, and post-hoc test (Tukey) for pairwise comparisons. Mann–Whitney test: for abnormally distributed quantitative variables, to compare between two studied groups. Kruskal–Wallis test: for abnormally distributed quantitative variables, to compare between more than two studied groups, and post hoc (Dunn's multiple-comparison test) for pairwise comparisons.

Sensitivity: the capacity of the test to correctly identify diseased individuals in a population 'true positives.' The greater the sensitivity, the smaller the number of unidentified case 'false negatives.'

Specificity: the capacity of the test to correctly exclude individuals who are free of the disease 'true negatives.' The greater the specificity, the fewer 'false positives' will be included.

Positive predictive value: the probability of the disease being present, among those with positive diagnostic test results.

Negative predictive value: the probability that the disease was absent among those whose diagnostic test results were negative.


  Results Top


Patients' characteristics: the clinical and baseline characteristics of the study population are depicted in [Table 1]. The prevalence of diabetes was significantly higher in the WRF group compared with other groups (P < 0.05), while there were no statistical significant differences among the studied groups regarding other characteristics [Table 1].
Table 1: Comparison between the three studied groups according to demographic data

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The mean left-ventricular end-diastolic and end-systolic diameters were significantly higher in the WRF group compared with SRF and IRF groups (P = 0.007 and 0.012, respectively). EF as well was significantly lower in the WRF group (47.69 ± 15) than the SRF (64.29 ± 15.2) and IRF groups (67.87 ± 6.1) (P < 0.001) [Table 2].
Table 2: Echocardiographic findings of the studied group

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The mean level of serum creatinine on admission was 1.12 ± 0.44 mg/dl in the SRF group, 1.51 ± 0.4 mg/dl in the IRF group, while it was 2.09 ± 0.76 mg/dl in the WRF group (P < 0.001). After 48 h, the mean level of serum creatinine was 1.12 ± 0.40 mg/dl in the SRF group, 1.26 ± 0.36 mg/dl in the IRF group, while it was 2.71 ± 0.80 mg/dl in the WRF group (P < 0.001). While at the time of discharge, the mean level of serum creatinine on discharge was 1.13 ± 0.4 mg/dl in the SRF group, 1.17 ± 0.31 mg/dl in the IRF group, and 2.74 ± 0.75 mg/dl in the WRF group (P < 0.001). The maximal change in the mean serum creatinine level in the SRF group was 0.06 ± 0.12 mg/dl. In the IRF group, the maximum change was −0.33 ± 0.17 and it was 0.84 ± 0.55 in the WRF group [Table 3].
Table 3: Comparison between the three studied groups according to serum creatinine

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Comparison between the studied groups according to the in-hospital outcome: during hospital stay, 37.5% of patients in the WRF group developed acute pulmonary edema, while only 7.2% of patients in the SRF group and 13.3% of patients in the IRF group developed acute pulmonary edema (P = 0.007). Cardiogenic shock was represented in 1.4% of patients in SRF and 25% of patients in WRF, while none of the patients in IRF developed cardiogenic shock (P = 0.006). Mechanical ventilation was required in 1.4% of patients in the SRF group and 6.7% of patients in the IRF group, while 25% patients in the WRF group required mechanical ventilation (P = 0.004). There were no statistical significant differences among the groups regarding development of new-onset atrial fibrillation during hospital stay [Table 4]. Regarding mortality in the study population during hospital stay, the number of deaths was significantly higher in the WRF group (81.2%) compared with the SRF group (13%) and IRF group (6.7%) (P < 0.001) [Table 4].
Table 4: Comparison between the three studied groups according to in-hospital management and outcome

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Sensitivity and specificity for baseline and peak serum creatinine to predicate mortality: serum creatinine cutoff value 1.4 mg/dl on admission had a sensitivity of 86.67%, specificity of 80%, and area under a curve of 0.902 to predict mortality with P value less than 0.001. Peak serum creatinine during admission cutoff value 2.3 mg/dl had a sensitivity of 93.33, specificity of 97.78, and area under a curve of 0.986 to predict mortality with P value less than 0.001 [Table 5].
Table 5: Sensitivity and specificity for baseline and peak serum creatinine to predicate mortality

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  Discussion Top


ACS is a leading cause of morbidity and mortality worldwide, and its incidence is projected to increase, especially in the developing world. Acute kidney injury is increasingly being seen in patients with ACSs. This condition has a complex pathogenesis, an incidence that can reach 30%, and it is associated with higher short-term and long-term morbidity and mortality [7].

Our study reported that ACS patients who demonstrated WRFs were older than who had stable or improving renal functions. These results are in agreement with Yadav et al. [8], Aguado-Romeo et al. [9], and Jose et al. [10].

Diabetes mellitus is a widespread risk factor for coronary artery disease and diabetes patients display a rapid decline in renal function [11]. The current study showed higher frequency of diabetes mellitus in the WRF group than the other two groups. This was concordant with Otsuka et al. [12] and Hashmi et al. [13].

The metabolism and excretion of troponins are affected by changes in serum creatinine clearance [14]. In this study, there was a statistically significant difference between the studied groups in regard to cardiac troponin I. These data are in agreement with most previous studies, except Ortega-Hernández et al. [15], who reported no statistically significant difference in serum troponin I level that could be explained by the higher percent of unstable angina in his study than ours.

In this study, patients with WRFs demonstrated lower LV EFs that those with stable and improving renal functions. These data are in agreement with Brezinov et al. [16].

STEMI was usually associated with more cardiac complications and serious arrhythmias than NSEMI/UA. In this study, mortality was higher in STEMI in comparison with NSTEMI. This is in agreement with Marceau et al. [17].

Acute kidney injury was an independent predictor of mortality in the hospital [18]. In our study, in-hospital adverse events were higher in patients who demonstrated WRFs. Moreover, during the follow-up period, nine (13%) patients died in the SRF group, one (6.7%) patient died in the IRF group, while in the WRF group, there were three patients who improved, while 13 (81.2%) patients died in the WRF group. Chehab et al. [19], Venkatason et al. [20], and Shacham et al. [21] reported similar in-hospital adverse outcome in ACS patients who developed acute kidney injury.

The results of this study demonstrate that serum creatinine at admission has a significant prognostic value in patients with ACS. In addition, the peak serum creatinine and the pattern of its change have also a prognostic value.

Previous investigators have reported that renal functions at hospital presentation have an ability to predict clinical course in both STEMI and NSTEMI patients. Fox et al. [22] in their registry reported that baseline serum creatinine predicted the short-term adverse outcome in both STEMI and NSTEMI patients. Marenzi et al. [23] demonstrated the impact of cardiac and renal functions on in-hospital morbidity and mortality in patients with acute myocardial infarction undergoing primary PCI. Szummer et al. [24] in their study about the impact of renal function on the results of early revascularization in NSTEMI, reported adverse cardiac events and new ischemic events in patients with WRF. Similarly, Gibson et al. [25] reported the association of glomerular filtration rate on presentation with subsequent mortality in NSTEMI.

According to these studies, serum creatinine or creatinine clearance on admission have been added in updated risk scores that predict morbidity and mortality in ACS as in the ACUITY-PCI risk score [26] and the CRUSADE risk score [27]. Similarly, development of acute kidney injury has been associated with increasing morbidity and mortality in ACS [28],[29].

In our study, we assessed the prognostic role of serum creatinine changes during hospital admission stay, which could also have a role similar to that reported by the baseline serum creatinine. Accordingly, we classified patients into three groups according to the pattern of their serum creatinine during admission period (improving, stable, and worsening). The main finding of this study was that worsening of serum creatinine during hospital admission period had a prognostic role better than baseline serum creatinine level. The higher capacity of peak serum creatinine level during admission period than the initial baseline level to predict mortality could be explained by the former that integrates all acute issues influencing renal function during ACS, including hemodynamic instability associated with ACS, effect of contrast used during PCI or bleeding, and, thus, to more accurately predict mortality, while the initial serum creatinine level mirrors only the cumulative effect of prior chronic kidney disease.

The results of this study highlight the importance of not only measuring baseline serum creatinine on hospital admission, but also that of daily evaluating it and determining its change pattern, in order to improve and update physicians on patient's risk profile.


  Conclusions Top


In ACS patients, daily serum creatinine level and its change patterns are strong predictors of in-hospital complications and mortality. Renal function test has a good prognostic value in identifying high-risk patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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