Predictors of Cardiovascular Death in ESRD

End stage renal disease (ESRD) is a situation with a cardiovascular risk profile of almost unique severity. While traditional risk factors dominate the scene in the general population, non traditional risk factors like inflammation (high C Reactive Protein, CRP), high brain natriuretic peptide, as an expression of left ventricular hypertrophy and left ventricular dysfunction, and accumulation of the endogenous inhibitor of the NO synthase, asymmetric dimethyl arginine are all markers of high CV risk of ESRD patients. To obtain a quantitative insight on the predictive power of traditional and emerging risk factors in ESRD, we performed a detailed multivariate survival analysis in the cardiovascular risk extended evaluation (CREED) cohort database. As expected, traditional risk factors (ie, age, sex, smoking, diabetes, and risk factors peculiar to the uremic state such as low serum albumin level) and treatment modality contributed to explain the all-cause mortality (37%) and cardiovascular variation mortality (24%) variation as well. When cardiovascular comorbidities were considered in this analysis, the explained variation in mortality increased to 45.4% and 36.4%, respectively. Furthermore, a combined score based on 2 biomarkers (brain natriuretic peptide and C-reactive protein levels) increased the explanatory power of these models by about 10%. In conclusion, traditional risk factors explain about half of all-cause and cardiovascular mortality variation in the ESRD population. The combined use of 2 biomarkers reflecting inflammation and left ventricular mass and function increases by about one fifth the explained mortality variation in this population. Biomarkers give information beyond that provided by traditional risk factors and therefore represent an useful adjunct for the definition of the risk profile of ESRD patients.

Keywords:  CRP , ADMA , BNP , cardiovascular risk , end-stage renal disease , prognosis , risk factor