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

Elevated Troponin in End-Stage Renal Disease (ESRD)

Yes, ESRD can and frequently does elevate troponin levels, with cardiac troponin T (cTnT) more commonly elevated than cardiac troponin I (cTnI) in the absence of acute coronary syndrome. 1

Prevalence and Magnitude of Troponin Elevation in ESRD

• Studies show that 99% of ESRD patients have elevated high-sensitivity cardiac troponin T (hs-cTnT) levels above the 99th percentile upper reference limit even without acute coronary syndrome 2
• Cardiac troponin T is elevated in approximately 42% of ESRD patients (>0.03 ng/mL) in the absence of acute myocardial ischemia 3
• The median hs-cTnT level in ESRD patients has been reported as 59.20 ng/L, which is significantly above the upper limit of normal (14 ng/L) 2
• Troponin I is less frequently elevated in ESRD patients compared to troponin T, with approximately 24% of ESRD patients showing elevated cTnI levels 3

Mechanisms of Troponin Elevation in ESRD

• Multiple cardiac and non-cardiac mechanisms contribute to troponin elevation in ESRD patients: 1

  • Underlying structural cardiac abnormalities, particularly left ventricular hypertrophy 1, 3
  • Decreased renal clearance of troponin fragments 1
  • Cardiac stress from volume overload common in ESRD 1
  • Silent ischemic heart disease and microinfarctions 4
  • Uremic skeletal myopathy 4
  • Unrecognized congestive heart failure 4

• Elevated troponin in ESRD is not merely a laboratory artifact but reflects true cardiac pathology, as confirmed by its significant correlation with left ventricular mass index 3

Clinical Implications for Diagnosis of Acute Coronary Syndrome

• 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% is necessary for diagnosis 1
  • Clinical context, including ischemic symptoms or ECG changes, is crucial 1

• A single troponin value should not be relied upon to diagnose or exclude acute myocardial infarction in ESRD patients 1, 4

Prognostic Significance

• Elevated troponin T (>0.1 ng/mL) in asymptomatic ESRD patients is significantly associated with increased all-cause mortality (relative risk, 2.64; 95% CI, 2.17 to 3.20) 5
• Elevated troponin T is also strongly associated with increased cardiac death in ESRD patients 5
• Elevated troponin in ESRD should not be dismissed as clinically insignificant, as it carries important prognostic information 1

Practical Considerations for Troponin Testing in ESRD

• In hemodialysis patients, blood samples for troponin should be collected before dialysis 6
• Recent hemodialysis can affect troponin levels, with studies showing decreases in hs-cTnT by up to 10-12% after dialysis 1
• Compared with cTnI, cTnT concentrations above the 99th percentile are more frequent among CKD patients in the absence of acute myocardial infarction 1
• The European Society of Cardiology notes that in elderly patients with renal dysfunction, elevations in cardiac troponin should not be primarily attributed to impaired clearance and considered harmless, as cardiac conditions such as chronic coronary syndromes or hypertensive heart disease are important contributors 6