Can End-Stage Renal Disease (ESRD) cause elevated troponin levels?

Elevated Troponin in End-Stage Renal Disease (ESRD)

Yes, ESRD can cause elevated troponin levels even in the absence of acute coronary syndrome. Patients with ESRD frequently have elevated baseline troponin levels due to multiple mechanisms, which can complicate the diagnosis of acute myocardial infarction in this population 1.

Mechanisms of Troponin Elevation in ESRD

• Troponin elevations in ESRD patients occur frequently, with cardiac troponin T (cTnT) more commonly elevated than cardiac troponin I (cTnI) in the absence of acute coronary syndrome 1
• Multiple mechanisms contribute to this elevation:
  • Underlying structural cardiac abnormalities including left ventricular hypertrophy 1
  • Subclinical myocardial damage from microinfarctions 2
  • Decreased renal clearance of troponin 1
  • Uremic cardiomyopathy 3
  • Cardiac stress from volume overload 1

Clinical Significance

• Elevated troponin in asymptomatic ESRD patients has important prognostic value:
  • cTnT levels >0.1 ng/mL are associated with increased all-cause mortality (relative risk 2.64) and cardiac death in ESRD patients 4
  • These elevations are not spurious findings but reflect underlying cardiovascular pathology 1
  • Elevated cTnT (>0.1 μg/L) increases the likelihood of finding significant coronary artery disease three-fold in high-risk ESRD patients 2

Diagnostic Challenges

• The diagnosis of acute myocardial infarction in ESRD patients requires:
  • Serial measurements showing a characteristic rise and/or fall pattern of troponin 1
  • For patients with already elevated baseline values, evidence of a rise of cardiac troponin values >20% if baseline values were elevated and stable or falling 1
  • Clinical context including ischemic symptoms or ECG changes 1
• Compared with cTnI, cTnT concentrations above the 99th percentile are more frequent among CKD patients in the absence of AMI (68% vs. 38% respectively) 1

Practical Approach to Troponin Interpretation in ESRD

• Do not automatically attribute elevated troponin to renal disease alone in the clinical context of chest pain or other symptoms suggestive of ACS 1
• Use serial measurements to detect significant changes indicative of acute myocardial injury 5
• Consider that optimal cut-off values for diagnosing MI in ESRD patients are higher than in the general population:
  • For hemodialysis patients: 75 ng/L for high-sensitivity troponin I 6
  • For peritoneal dialysis patients: 144 ng/L for high-sensitivity troponin I 6
• Recent hemodialysis can affect troponin levels, with studies showing decreases in hs-cTnT by up to 10-12% after dialysis 1

Key Pitfalls to Avoid

• Do not dismiss elevated troponin in ESRD patients as clinically insignificant, as it carries important prognostic information 1, 4
• Do not rely on a single troponin value to diagnose or exclude acute myocardial infarction in ESRD patients 1, 5
• Do not use the same diagnostic thresholds as in patients with normal renal function 6
• Remember that the dialysis modality (hemodialysis vs. peritoneal dialysis) affects the optimal cut-off values for troponin interpretation 6