Ann Intern Med. 2014 Oct 7;161(7):491-501. doi: 10.7326/M14-0743.
Clinicians face uncertainty about the prognostic value of troponin testing in patients with chronic kidney disease (CKD) without suspected acute coronary syndrome (ACS).
To systematically review the literature on troponin testing in patients with CKD without ACS.
MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through May 2014.
Studies examining elevated versus normal troponin levels in patients with CKD without ACS.
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.
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.
Studies were heterogeneous regarding assays, troponin cut points, covariate adjustment, and follow-up.
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.
Agency for Healthcare Research and Quality.
临床医生在面对慢性肾脏病（CKD）患者无急性冠状动脉综合征（ACS）疑似症状时，对于肌钙蛋白检测的预后价值存在不确定性。
系统回顾无 ACS 的 CKD 患者肌钙蛋白检测的文献。
MEDLINE、EMBASE 和 Cochrane 对照试验中心注册库，检索截至 2014 年 5 月。
研究检查了 CKD 无 ACS 患者中升高与正常肌钙蛋白水平。
配对评审员选择纳入的文章，提取数据，并对证据强度（SOE）进行分级。当研究具有足够关键变量的同质性时，进行了荟萃分析。
98 项研究符合纳入标准。接受透析治疗的患者中，升高的肌钙蛋白水平与全因和心血管死亡率相关（中等 SOE）。调整年龄和冠状动脉疾病或风险等效因素后，来自研究的全因死亡率的合并危险比（HR）为肌钙蛋白 T 3.0（95%CI，2.4 至 4.3），肌钙蛋白 I 为 2.7（CI，1.9 至 4.6）。心血管死亡率的合并调整 HR 为肌钙蛋白 T 3.3（CI，1.8 至 5.4），肌钙蛋白 I 为 4.2（CI，2.0 至 9.2）。未接受透析治疗的 CKD 患者中发现结果相似，但研究较少。没有研究通过肌钙蛋白切点测试治疗策略。
研究在检测方法、肌钙蛋白切点、协变量调整和随访方面存在差异。
在无 ACS 疑似症状的 CKD 患者中，升高的肌钙蛋白水平与预后不良相关。未来的研究应集中于该生物标志物是否比临床模型更适合重新分类 CKD 患者的风险，以及这种分类是否有助于指导风险最高的死亡患者的治疗。
医疗保健研究与质量局。
