Troponin i and NT-proBNP and the association of systolic blood pressure with outcomes in incident hemodialysis patients

The choices for healthy outcomes in caring for ESRD (CHOICE) study

Tariq Shafi, Philip G. Zager, Stephen M Sozio, Morgan Grams, Bernard Jaar, Robert H. Christenson, Leigh Boulware, Rulan S. Parekh, Neil R. Powe, Josef Coresh

Research output: Contribution to journalArticle

Abstract

Background There is uncertainty regarding treatment of hypertension in hemodialysis patients due to the observed J-shaped association between blood pressure (BP) and death. We hypothesized that this association reflects confounding by cardiovascular disease (CVD) and that stratification by CVD biomarkers, cardiac troponin I (cTnI) and N-terminal fragment of prohormone brain natriuretic peptide (NT-proBNP), might change this association. Study Design National prospective cohort study. Setting & Participants 446 incident hemodialysis patients. Predictor Predialysis systolic BP. Outcomes Mortality (all-cause and CVD) and first CVD event assessed using Cox regression adjusted for demographics, comorbid conditions, and clinical factors. Measurements Participants with cTnI level ≥ 0.1 ng/mL or NT-proBNP level ≥ 9,252 pg/mL were classified as the high-biomarker group; remaining participants were included in the low-biomarker group. Results Participants in the high-biomarker group (n = 138 [31%]) were older (61 vs 57 years) and had a higher prevalence of CVD (67% vs 23%), but similar baseline BPs (152 vs 153 mm Hg). There were 323 deaths (143 from CVD) and 271 CVD events. The high-biomarker group had a higher risk of mortality than the low-biomarker group (HR, 1.75; 95% CI, 1.37-2.24). The association between BP and outcomes differed between the 2 biomarker groups (P for interaction = 0.01, 0.2, and 0.07 for all-cause mortality, CVD mortality, and first CVD event, respectively). In the low-biomarker group, BP was associated with greater risk of outcomes: HR per 10 mm Hg higher BP was 1.07 (95% CI, 1.01-1.14), 1.10 (95% CI, 0.96-1.25), and 1.04 (95% CI, 0.96-1.13) for all-cause mortality, CVD mortality, and first CVD event, respectively. Importantly, lower BP was not associated with increased risk of outcomes in stratified models, including for those in high biomarker group. Limitations BP measurements not standardized. Conclusions The observed J-shaped association between BP and outcomes in hemodialysis patients is due to confounding by subclinical CVD. A stratification approach based on cTnI and NT-proBNP levels has the potential to inform BP treatment in hemodialysis patients.

Original languageEnglish (US)
Pages (from-to)443-451
Number of pages9
JournalAmerican Journal of Kidney Diseases
Volume64
Issue number3
DOIs
StatePublished - 2014

Fingerprint

Troponin
Chronic Kidney Failure
Renal Dialysis
Cardiovascular Diseases
Blood Pressure
Biomarkers
Troponin I
Mortality
pro-brain natriuretic peptide (1-76)
Hypertension
Brain Natriuretic Peptide
Uncertainty
Cohort Studies
Demography

Keywords

  • dialysis
  • End-stage renal disease (ESRD)
  • epidemiology
  • hemodialysis
  • hypertension
  • mortality
  • N-terminal pro-brain natriuretic peptide (NT-proBNP)
  • outcomes
  • systolic blood pressure
  • troponin I

ASJC Scopus subject areas

  • Nephrology

Cite this

@article{6a31f0f422de41faae31638aec2b2086,
title = "Troponin i and NT-proBNP and the association of systolic blood pressure with outcomes in incident hemodialysis patients: The choices for healthy outcomes in caring for ESRD (CHOICE) study",
abstract = "Background There is uncertainty regarding treatment of hypertension in hemodialysis patients due to the observed J-shaped association between blood pressure (BP) and death. We hypothesized that this association reflects confounding by cardiovascular disease (CVD) and that stratification by CVD biomarkers, cardiac troponin I (cTnI) and N-terminal fragment of prohormone brain natriuretic peptide (NT-proBNP), might change this association. Study Design National prospective cohort study. Setting & Participants 446 incident hemodialysis patients. Predictor Predialysis systolic BP. Outcomes Mortality (all-cause and CVD) and first CVD event assessed using Cox regression adjusted for demographics, comorbid conditions, and clinical factors. Measurements Participants with cTnI level ≥ 0.1 ng/mL or NT-proBNP level ≥ 9,252 pg/mL were classified as the high-biomarker group; remaining participants were included in the low-biomarker group. Results Participants in the high-biomarker group (n = 138 [31{\%}]) were older (61 vs 57 years) and had a higher prevalence of CVD (67{\%} vs 23{\%}), but similar baseline BPs (152 vs 153 mm Hg). There were 323 deaths (143 from CVD) and 271 CVD events. The high-biomarker group had a higher risk of mortality than the low-biomarker group (HR, 1.75; 95{\%} CI, 1.37-2.24). The association between BP and outcomes differed between the 2 biomarker groups (P for interaction = 0.01, 0.2, and 0.07 for all-cause mortality, CVD mortality, and first CVD event, respectively). In the low-biomarker group, BP was associated with greater risk of outcomes: HR per 10 mm Hg higher BP was 1.07 (95{\%} CI, 1.01-1.14), 1.10 (95{\%} CI, 0.96-1.25), and 1.04 (95{\%} CI, 0.96-1.13) for all-cause mortality, CVD mortality, and first CVD event, respectively. Importantly, lower BP was not associated with increased risk of outcomes in stratified models, including for those in high biomarker group. Limitations BP measurements not standardized. Conclusions The observed J-shaped association between BP and outcomes in hemodialysis patients is due to confounding by subclinical CVD. A stratification approach based on cTnI and NT-proBNP levels has the potential to inform BP treatment in hemodialysis patients.",
keywords = "dialysis, End-stage renal disease (ESRD), epidemiology, hemodialysis, hypertension, mortality, N-terminal pro-brain natriuretic peptide (NT-proBNP), outcomes, systolic blood pressure, troponin I",
author = "Tariq Shafi and Zager, {Philip G.} and Sozio, {Stephen M} and Morgan Grams and Bernard Jaar and Christenson, {Robert H.} and Leigh Boulware and Parekh, {Rulan S.} and Powe, {Neil R.} and Josef Coresh",
year = "2014",
doi = "10.1053/j.ajkd.2014.03.015",
language = "English (US)",
volume = "64",
pages = "443--451",
journal = "American Journal of Kidney Diseases",
issn = "0272-6386",
publisher = "W.B. Saunders Ltd",
number = "3",

}

TY - JOUR

T1 - Troponin i and NT-proBNP and the association of systolic blood pressure with outcomes in incident hemodialysis patients

T2 - The choices for healthy outcomes in caring for ESRD (CHOICE) study

AU - Shafi, Tariq

AU - Zager, Philip G.

AU - Sozio, Stephen M

AU - Grams, Morgan

AU - Jaar, Bernard

AU - Christenson, Robert H.

AU - Boulware, Leigh

AU - Parekh, Rulan S.

AU - Powe, Neil R.

AU - Coresh, Josef

PY - 2014

Y1 - 2014

N2 - Background There is uncertainty regarding treatment of hypertension in hemodialysis patients due to the observed J-shaped association between blood pressure (BP) and death. We hypothesized that this association reflects confounding by cardiovascular disease (CVD) and that stratification by CVD biomarkers, cardiac troponin I (cTnI) and N-terminal fragment of prohormone brain natriuretic peptide (NT-proBNP), might change this association. Study Design National prospective cohort study. Setting & Participants 446 incident hemodialysis patients. Predictor Predialysis systolic BP. Outcomes Mortality (all-cause and CVD) and first CVD event assessed using Cox regression adjusted for demographics, comorbid conditions, and clinical factors. Measurements Participants with cTnI level ≥ 0.1 ng/mL or NT-proBNP level ≥ 9,252 pg/mL were classified as the high-biomarker group; remaining participants were included in the low-biomarker group. Results Participants in the high-biomarker group (n = 138 [31%]) were older (61 vs 57 years) and had a higher prevalence of CVD (67% vs 23%), but similar baseline BPs (152 vs 153 mm Hg). There were 323 deaths (143 from CVD) and 271 CVD events. The high-biomarker group had a higher risk of mortality than the low-biomarker group (HR, 1.75; 95% CI, 1.37-2.24). The association between BP and outcomes differed between the 2 biomarker groups (P for interaction = 0.01, 0.2, and 0.07 for all-cause mortality, CVD mortality, and first CVD event, respectively). In the low-biomarker group, BP was associated with greater risk of outcomes: HR per 10 mm Hg higher BP was 1.07 (95% CI, 1.01-1.14), 1.10 (95% CI, 0.96-1.25), and 1.04 (95% CI, 0.96-1.13) for all-cause mortality, CVD mortality, and first CVD event, respectively. Importantly, lower BP was not associated with increased risk of outcomes in stratified models, including for those in high biomarker group. Limitations BP measurements not standardized. Conclusions The observed J-shaped association between BP and outcomes in hemodialysis patients is due to confounding by subclinical CVD. A stratification approach based on cTnI and NT-proBNP levels has the potential to inform BP treatment in hemodialysis patients.

AB - Background There is uncertainty regarding treatment of hypertension in hemodialysis patients due to the observed J-shaped association between blood pressure (BP) and death. We hypothesized that this association reflects confounding by cardiovascular disease (CVD) and that stratification by CVD biomarkers, cardiac troponin I (cTnI) and N-terminal fragment of prohormone brain natriuretic peptide (NT-proBNP), might change this association. Study Design National prospective cohort study. Setting & Participants 446 incident hemodialysis patients. Predictor Predialysis systolic BP. Outcomes Mortality (all-cause and CVD) and first CVD event assessed using Cox regression adjusted for demographics, comorbid conditions, and clinical factors. Measurements Participants with cTnI level ≥ 0.1 ng/mL or NT-proBNP level ≥ 9,252 pg/mL were classified as the high-biomarker group; remaining participants were included in the low-biomarker group. Results Participants in the high-biomarker group (n = 138 [31%]) were older (61 vs 57 years) and had a higher prevalence of CVD (67% vs 23%), but similar baseline BPs (152 vs 153 mm Hg). There were 323 deaths (143 from CVD) and 271 CVD events. The high-biomarker group had a higher risk of mortality than the low-biomarker group (HR, 1.75; 95% CI, 1.37-2.24). The association between BP and outcomes differed between the 2 biomarker groups (P for interaction = 0.01, 0.2, and 0.07 for all-cause mortality, CVD mortality, and first CVD event, respectively). In the low-biomarker group, BP was associated with greater risk of outcomes: HR per 10 mm Hg higher BP was 1.07 (95% CI, 1.01-1.14), 1.10 (95% CI, 0.96-1.25), and 1.04 (95% CI, 0.96-1.13) for all-cause mortality, CVD mortality, and first CVD event, respectively. Importantly, lower BP was not associated with increased risk of outcomes in stratified models, including for those in high biomarker group. Limitations BP measurements not standardized. Conclusions The observed J-shaped association between BP and outcomes in hemodialysis patients is due to confounding by subclinical CVD. A stratification approach based on cTnI and NT-proBNP levels has the potential to inform BP treatment in hemodialysis patients.

KW - dialysis

KW - End-stage renal disease (ESRD)

KW - epidemiology

KW - hemodialysis

KW - hypertension

KW - mortality

KW - N-terminal pro-brain natriuretic peptide (NT-proBNP)

KW - outcomes

KW - systolic blood pressure

KW - troponin I

UR - http://www.scopus.com/inward/record.url?scp=84908129333&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84908129333&partnerID=8YFLogxK

U2 - 10.1053/j.ajkd.2014.03.015

DO - 10.1053/j.ajkd.2014.03.015

M3 - Article

VL - 64

SP - 443

EP - 451

JO - American Journal of Kidney Diseases

JF - American Journal of Kidney Diseases

SN - 0272-6386

IS - 3

ER -