Clinical Cases: hs-TnT in Patients with End Stage Renal Failure

In a subset of patients with end-stage renal disease (ESRD), the NACB guidelines 29 have recommended a change in the cTn concentration of ≥20% for the diagnosis of MI, in those who present with elevated cTn, 6–9 h after presentation, as indicative of a relevant concentration change because it represents a significant (3SD) change in cTn on the basis of a 5–7% analytical CV.¹

In the present case, ESRD patient on dialysis with evidence of LVH and Chronic Heart disease is exhibiting non-specific chest pain symptoms. The serial measurement of troponin T in serum is useful to rule out AMI as there is no dynamic rise and or fall of its level within 48hrs.

Serial measurement of cTnT improves the diagnostic accuracy in patients with renal dysfunction.

Case 7

73-year-old male

Key signs and symptoms

Hypotension and short stabbing chest pain during dialysis, nausea

Medical history

Diabetes mellitus for 12 years, on dialysis for the past 2 years, hypertension for many years

Clinical examination

Third heart sound, BP 95/60mmHg, lungs normal, no edema; Normal ECG

Laboratory test results

Results		Reference range
CRP 3 mg/L		<5 mg/dL
Serum creatinine 7,5 mg/dL		<9 mg/dL
Hb 10,2 g/dL		Male: 13–18 g/dL / Female: 12–16 g/dL
GFR 7 mL/min/1,73 m²		>90 mL/min/1,73 m²

ECG

Left ventricular hypertrophy with positive Sokolow index and discordant ST segment changes in the lateral chest leads.

Troponin kinetic profile

Coronary angiography

Coronary angiogram showing a corkscrew-like tortuosity of the left circumflex artery accompanied by chronic hypertension.

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Diagnosis

End stage renal failure

The patient had experienced non-specific symptoms during dialysis. The ECG showed signs of left ventricular hypertrophy, while the coronary angiogram revealed a corkscrew-like tortuosity of the left circumflex artery accompanied by chronic hypertension. Given the high clinical likelihood of CHD, careful assessment is required. Furthermore, since elevated cTnT-hs levels would be expected in these patients, serial measurements are needed. According to the recommendation published by the NACB8, based on the use of less sensitive cTn generations (e.g. cTnT Gen 4), an increase of more than 20 % for a repeat measurement after 6 – 9 hours is indicative of an acute event.²²

Diagnosis

End stage renal failure

Conclusion

There is no rise or fall in cTnT-hs values needed for AMI diagnosis.

References