Nisha Bansal1, Leila R Zelnick2, Christie M Ballantyne3, Paulo H M Chaves4, Robert H Christenson5, Josef Coresh6, Christopher R deFilippi7, James A de Lemos8, Lori B Daniels9, Alan S Go10, Jiang He11, S Susan Hedayati12, Kunihiro Matsushita6, Vijay Nambi13, Michael G Shlipak14, Jonathan J Taliercio15, Stephen L Seliger16. 1. Kidney Research Institute and Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington. Electronic address: nbansal@nephrology.washington.edu. 2. Kidney Research Institute and Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington. 3. Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, Texas. 4. Benjamin Leon Center for Geriatric Research and Education, Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida. 5. Department of Pathology, School of Medicine, University of Maryland, Baltimore, Maryland. 6. Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. 7. Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia. 8. Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas. 9. Division of Cardiovascular Medicine, Department of Medicine, and Division of Epidemiology, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California. 10. Division of Research, Kaiser Permanente Northern California, Oakland, California. 11. Tulane University Translational Science Institute, Department of Epidemiology, School of Public Health & Tropical Medicine, Tulane University, New Orleans, Louisiana. 12. Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas. 13. Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, Texas; Michael E. DeBakey Veterans Affairs Hospital, Houston, Texas. 14. Department of Medicine, and Department of Epidemiology and Biostatistics, University of California-San Francisco, and San Francisco VA Medical Center, San Francisco, California. 15. Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio. 16. Division of Nephrology, School of Medicine, University of Maryland, Baltimore, Maryland.
Abstract
RATIONALE & OBJECTIVE: The utility of conventional upper reference limits (URL) for N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hsTnT) in chronic kidney disease (CKD) remains debated. We analyzed the distribution of hsTnT and NT-proBNP in people with CKD in ambulatory settings to examine the diagnostic value of conventional URL in this population. STUDY DESIGN: Observational study. SETTING & PARTICIPANTS: We studied participants of the Chronic Renal Insufficiency Cohort (CRIC) with CKD and no self-reported history of cardiovascular disease. EXPOSURE: Estimated glomerular filtration rate (eGFR). OUTCOME: NT-proBNP and hsTnT at baseline. ANALYTICAL APPROACH: We described the proportion of participants above the conventional URL for NT-proBNP (125pg/mL) and hsTnT (14ng/L) overall and by eGFR. We then estimated 99th percentile URL for NT-proBNP and hsTnT. Using quantile regression of the 99th percentile, we modeled the association of eGFR with NT-proBNP and hsTnT. RESULTS: Among 2,312 CKD participants, 40% and 43% had levels of NT-proBNP and hsTnT above the conventional URL, respectively. In those with eGFR <30mL/min/1.73m2, 71% and 68% of participants had concentrations of NT-proBNP and hsTnT above the conventional URL, respectively. Among all CKD participants, the 99th percentile for NT-proBNP was 3,592 (95% CI, 2,470-4,849) pg/mL and for hsTnT it was 126 (95% CI, 100-144) ng/L. Each 15mL/min/1.73m2 decrement in eGFR was associated with a ~40% higher threshold for the 99th percentile of NT-proBNP (1.43 [95% CI, 1.21-1.69]) and hsTnT (1.45 [95% CI, 1.31-1.60]). LIMITATIONS: Study included ambulatory patients, and we could not test the accuracy of the URL of NT-proBNP and hsTnT in the acute care setting. CONCLUSIONS: In this ambulatory CKD population with no self-reported history of cardiovascular disease, a range of 40%-88% of participants had concentrations of NT-proBNP and hsTnT above the conventional URL, depending on eGFR strata. Developing eGFR-specific thresholds for these commonly used cardiac biomarkers in the setting of CKD may improve their utility for evaluation of suspected heart failure and myocardial infarction.
RATIONALE & OBJECTIVE: The utility of conventional upper reference limits (URL) for N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hsTnT) in chronic kidney disease (CKD) remains debated. We analyzed the distribution of hsTnT and NT-proBNP in people with CKD in ambulatory settings to examine the diagnostic value of conventional URL in this population. STUDY DESIGN: Observational study. SETTING & PARTICIPANTS: We studied participants of the Chronic Renal Insufficiency Cohort (CRIC) with CKD and no self-reported history of cardiovascular disease. EXPOSURE: Estimated glomerular filtration rate (eGFR). OUTCOME: NT-proBNP and hsTnT at baseline. ANALYTICAL APPROACH: We described the proportion of participants above the conventional URL for NT-proBNP (125pg/mL) and hsTnT (14ng/L) overall and by eGFR. We then estimated 99th percentile URL for NT-proBNP and hsTnT. Using quantile regression of the 99th percentile, we modeled the association of eGFR with NT-proBNP and hsTnT. RESULTS: Among 2,312 CKD participants, 40% and 43% had levels of NT-proBNP and hsTnT above the conventional URL, respectively. In those with eGFR <30mL/min/1.73m2, 71% and 68% of participants had concentrations of NT-proBNP and hsTnT above the conventional URL, respectively. Among all CKD participants, the 99th percentile for NT-proBNP was 3,592 (95% CI, 2,470-4,849) pg/mL and for hsTnT it was 126 (95% CI, 100-144) ng/L. Each 15mL/min/1.73m2 decrement in eGFR was associated with a ~40% higher threshold for the 99th percentile of NT-proBNP (1.43 [95% CI, 1.21-1.69]) and hsTnT (1.45 [95% CI, 1.31-1.60]). LIMITATIONS: Study included ambulatory patients, and we could not test the accuracy of the URL of NT-proBNP and hsTnT in the acute care setting. CONCLUSIONS: In this ambulatory CKD population with no self-reported history of cardiovascular disease, a range of 40%-88% of participants had concentrations of NT-proBNP and hsTnT above the conventional URL, depending on eGFR strata. Developing eGFR-specific thresholds for these commonly used cardiac biomarkers in the setting of CKD may improve their utility for evaluation of suspected heart failure and myocardial infarction.
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