Dr. Akshay S. Desai (AD), cardiologist from Harvard Medical School, spoke with Dr Kellie Calderon (eAJKD), eAJKD web advisory board member, on the use of cardiac biomarkers in chronic kidney disease (CKD). In CKD, elevations of cardiac biomarkers are common. Troponin T and N-terminal pro brain natriuretic peptide are potential markers of cardiac injury that are often measured in the inpatient setting. Can these markers be used in the outpatient setting to predict risk of developing ESRD in patients with diabetic kidney disease?

eAJKD: Why did you initiate this study?

AD: We wanted to shed light on the relationship between cardiac injury and progression of chronic kidney disease.  Both in the emergency room and inpatient setting, clinicians  treating CKD patients commonly encounter elevated Troponin T (TnT) and N-terminal pro B-type natriuretic peptide BNP (NT-proBNP) levels.  While these cardiac biomarker elevations are known to be associated with increased risk for cardiovascular events, their potential association with the development of end stage renal disease is not well described. In our study, we evaluated baseline levels of TnT and NT-proBNP in the first 1000 patients with Type 2 diabetes, CKD, and anemia enrolled in the TREAT trial. The association between cardiac biomarker levels and the subsequent development of ESRD was analyzed in multivariable models.

eAJKD: Did you find any surprising associations?

AD: Yes. We noted that even in ambulatory CKD patients, cardiac biomarker levels are frequently elevated.  Moreover, levels of both TnT and NT-proBNP appear to be associated with the risk for subsequent development of ESRD, even after adjustment for conventional risk factors including eGFR and proteinuria. These data suggest a link between cardiac injury and CKD progression that further underscores the notion of a “cardio-renal” connection.

eAJKD: How can one use this information in future clinical practice and research?

AD: I think we may be able to use this information to improve risk stratification for both cardiac and renal outcomes in CKD patients. . Measurement of TnT and NT-pro-BNP may facilitate identification of patients with CKD who are at highest risk for developing ESRD, allowing clinicians to appropriately counsel patients and make the necessary advance preparations.  However, these results, derived from a clinical trial that enrolled patients with diabetes, anemia, and CKD require validation in other cohorts before being incorporated into routine clinical practice.

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