Prognostic value of cardiac troponin in patients with chronic kidney disease without suspected acute coronary syndrome: a systematic review and meta-analysis.

BACKGROUND

Clinicians face uncertainty about the prognostic value of troponin testing in patients with chronic kidney disease (CKD) without suspected acute coronary syndrome (ACS).

PURPOSE

To systematically review the literature on troponin testing in patients with CKD without ACS.

DATA SOURCES

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through May 2014.

STUDY SELECTION

Studies examining elevated versus normal troponin levels in patients with CKD without ACS.

DATA EXTRACTION

Paired reviewers selected articles for inclusion, extracted data, and graded strength of evidence (SOE). Meta-analyses were conducted when studies had sufficient homogeneity of key variables.

DATA SYNTHESIS

Ninety-eight studies met inclusion criteria. Elevated troponin levels were associated with all-cause and cardiovascular mortality among patients receiving dialysis (moderate SOE). Pooled hazard ratios (HRs) for all-cause mortality from studies that adjusted for age and coronary artery disease or a risk equivalent were 3.0 (95% CI, 2.4 to 4.3) for troponin T and 2.7 (CI, 1.9 to 4.6) for troponin I. The pooled adjusted HRs for cardiovascular mortality were 3.3 (CI, 1.8 to 5.4) for troponin T and 4.2 (CI, 2.0 to 9.2) for troponin I. Findings were similar for patients with CKD who were not receiving dialysis, but there were fewer studies. No study tested treatment strategies by troponin cut points.

LIMITATION

Studies were heterogeneous regarding assays, troponin cut points, covariate adjustment, and follow-up.

CONCLUSION

In patients with CKD without suspected ACS, elevated troponin levels were associated with worse prognosis. Future studies should focus on whether this biomarker is more appropriate than clinical models for reclassifying risk of patients with CKD and whether such classification can help guide treatment in those at highest risk for death.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.