Department of Laboratory Medicine and Pathology and.
Division of Cardiology, Hennepin County Medical Center, Minneapolis, Minnesota.
J Am Soc Nephrol. 2018 Feb;29(2):636-643. doi: 10.1681/ASN.2017030341. Epub 2017 Oct 27.
Measures of cardiac troponin (cTn) may have lower specificity for myocardial infarction in patients with CKD. We examined the diagnostic accuracy of baseline and serial high-sensitivity cTnI (hs-cTnI) measurements for myocardial infarction and 30- and 180-day mortality according to renal function. hs-cTnI was measured (Abbott assay) using sex-specific 99th percentiles (women, 16 ng/L; men, 34 ng/L) in 1555 adults presenting to the emergency department with symptoms suggesting ischemia (NCT02060760). Myocardial infarction was adjudicated along universal definition classification. Renal function did not significantly affect sensitivity or negative predictive values. Specificity decreased with impaired renal function from 93%-95% with normal function (eGFR≥90 ml/min per 1.73 m; =722) to 57%-61% with severely impaired renal function (eGFR<30 ml/min per 1.73 m; =81) and 40%-41% on dialysis (=78). Positive predictive values decreased with decreasing renal function from 51%-57% with normal function to 27%-42% with severely impaired function and 15%-32% on dialysis. Receiver operating characteristic curve areas trended lower at baseline and 3 hours with renal impairment. Mortality increased significantly with increasing hs-cTnI tertile (1.3%, 6.0%, and 10.4%, respectively). Patients with hs-cTnI concentration exceeding concentrations in the 99th percentiles had a mortality rate (11.7%) significantly higher than that of patients with concentrations between 99th percentile concentrations and limit of detection (6.2%) or below limit of detection (1.1%). Renal dysfunction and dialysis reduced the rule-in performance but not the rule-out performance of hs-cTnI for myocardial infarction, and mortality increased in patients with higher hs-cTnI concentrations and any level of renal dysfunction.
肌钙蛋白（cTn）的测定可能对慢性肾脏病患者的心肌梗死特异性较低。我们根据肾功能检查了基线和连续高敏肌钙蛋白 I（hs-cTnI）测定对心肌梗死和 30 天及 180 天死亡率的诊断准确性。1555 例因疑似缺血症状就诊于急诊室的成人患者采用雅培检测法测定 hs-cTnI（女性 16ng/L，男性 34ng/L），（NCT02060760）。采用通用定义标准对心肌梗死进行判定。肾功能并未显著影响敏感性或阴性预测值。特异性随肾功能受损而降低，从正常功能（eGFR≥90ml/min/1.73m2；=722）到严重肾功能受损（eGFR<30ml/min/1.73m2；=81）为 93%-95%，再到透析（=78）为 57%-61%。阳性预测值随肾功能下降而降低，从正常功能的 51%-57%下降至严重肾功能受损时的 27%-42%，透析时为 15%-32%。基线和 3 小时时，肾功能受损时接受者操作特征曲线下面积呈下降趋势。hs-cTnI 三分位数越高，死亡率显著升高（分别为 1.3%、6.0%和 10.4%）。hs-cTnI 浓度超过第 99 百分位浓度的患者死亡率（11.7%）显著高于浓度在第 99 百分位浓度与检测限之间（6.2%）或低于检测限（1.1%）的患者。肾功能不全和透析降低了 hs-cTnI 对心肌梗死的纳入标准性能，但不降低排除标准性能，hs-cTnI 浓度较高且任何程度肾功能不全的患者死亡率均升高。
