Kidney transplantation from donors after cardiac death: a 25-year experience.

BACKGROUND.: The shortage of organ donors presents a major obstacle for adequate treatment of patients with end-stage renal disease. Donation after cardiac death (DCD) has been shown to increase the number of kidneys available for transplantation. The present article reports on the first 25 years of our experience with DCD kidney transplantation. METHODS.: This observational cohort study included all DCD kidney transplantations recovered in our procurement area from January 1, 1981 until December 31, 2005 (n=297). Patients were followed up until the earliest of death or December 31, 2006. Clinical outcomes were compared with matched kidney transplantations from brain dead donors (DBD, n=594), using multivariable regression models to adjust for potential confounders. RESULTS.: DCD activity resulted in a 44% increase in the number of deceased donor kidneys from our organ procurement area. After adjustment for potential confounders, the odds of primary nonfunction and delayed graft function were 7.5 (95% CI, 4.0-14.1; P<0.001) and 10.3 (95% CI, 6.7-15.9; P<0.001) times greater, respectively, for DCD kidneys compared with DBD kidneys. The high incidence of primary nonfunction of DCD kidneys resulted in an increased rate of graft loss (HR, 1.82; 95% CI, 1.37-2.42; P<0.001). However, DCD kidneys that did not experience primary nonfunction functioned as long as DBD kidneys (HR, 1.05; 95% CI, 0.73-1.51; P=0.79). Patient survival of DCD and DBD kidney recipients was equivalent (HR, 1.16; 95% CI, 0.87-1.54; P=0.32). CONCLUSIONS.: The benefits of DCD kidney transplantation outweigh the increased risk of early graft loss. Expansion of the supply of DCD kidneys is likely to improve the treatment of wait-listed dialysis patients

High-sensitivity cardiac troponin t: Risk stratification tool in patients with symptoms of chest discomfort

BACKGROUND: Recent studies have demonstrated the association between increased concentrations of high-sensitivity cardiac troponin T (hs-cTnT) and the incidence of myocardial infarction, heart failure, and mortality. However, most prognostic studies to date focus on the value of hs-cTnT in the elderly or general population. The value of hs-cTnT in symptomatic patients visiting the outpatient department remains unclear. The aim of this study was to investigate the prognostic value of hs-cTnT as a biomarker in patients with symptoms of chest discomfort suspected for coronary artery disease and to assess its additional value in combination with other risk stratification tools in predicting cardiac events. METHODS: We studied 1,088 patients (follow-up 2.2 +/- 0.8 years) with chest discomfort who underwent coronary calcium scoring and coronary CT-angiography. Traditional cardiovascular risk factors and concentrations of hs-cTnT, N-terminal pro-brain-type natriuretic peptide (NT-proBNP) and high-sensitivity C-reactive protein (hsCRP) were assessed. Study endpoint was the occurrence of late coronary revascularization (>90 days), acute coronary syndrome, and cardiac mortality. RESULTS: Hs-cTnT was a significant predictor for the composite endpoint (highest quartile [Q4]>6.7 ng/L, HR 3.55; 95%CI 1.88-6.70; P<0.001). Survival analysis showed that hs-cTnT had significant predictive value on top of current risk stratification tools (Chi-square change P<0.01). In patients with hs-cTnT in Q4 versus <Q4, a 2- to 3-fold increase in cardiovascular risk was noticed, either when corrected for high or low Framingham risk score, coronary calcium scoring, or CT-angiography assessment (HR 3.11; 2.73; 2.47; respectively; all P<0.01). This was not the case for hsCRP and NT-proBNP. CONCLUSIONS: Hs-cTnT is a useful prognostic biomarker in patients with chest discomfort suspected for coronary artery disease. In addition, hs-cTnT was an independent predictor for cardiac events when corrected for cardiovascular risk profiling, calcium score and CT-angiography results

High-sensitivity cardiac troponin t: Risk stratification tool in patients with symptoms of chest discomfort

BACKGROUND: Recent studies have demonstrated the association between increased concentrations of high-sensitivity cardiac troponin T (hs-cTnT) and the incidence of myocardial infarction, heart failure, and mortality. However, most prognostic studies to date focus on the value of hs-cTnT in the elderly or general population. The value of hs-cTnT in symptomatic patients visiting the outpatient department remains unclear. The aim of this study was to investigate the prognostic value of hs-cTnT as a biomarker in patients with symptoms of chest discomfort suspected for coronary artery disease and to assess its additional value in combination with other risk stratification tools in predicting cardiac events. METHODS: We studied 1,088 patients (follow-up 2.2 +/- 0.8 years) with chest discomfort who underwent coronary calcium scoring and coronary CT-angiography. Traditional cardiovascular risk factors and concentrations of hs-cTnT, N-terminal pro-brain-type natriuretic peptide (NT-proBNP) and high-sensitivity C-reactive protein (hsCRP) were assessed. Study endpoint was the occurrence of late coronary revascularization (>90 days), acute coronary syndrome, and cardiac mortality. RESULTS: Hs-cTnT was a significant predictor for the composite endpoint (highest quartile [Q4]>6.7 ng/L, HR 3.55; 95%CI 1.88-6.70; P<0.001). Survival analysis showed that hs-cTnT had significant predictive value on top of current risk stratification tools (Chi-square change P<0.01). In patients with hs-cTnT in Q4 versus <Q4, a 2- to 3-fold increase in cardiovascular risk was noticed, either when corrected for high or low Framingham risk score, coronary calcium scoring, or CT-angiography assessment (HR 3.11; 2.73; 2.47; respectively; all P<0.01). This was not the case for hsCRP and NT-proBNP. CONCLUSIONS: Hs-cTnT is a useful prognostic biomarker in patients with chest discomfort suspected for coronary artery disease. In addition, hs-cTnT was an independent predictor for cardiac events when corrected for cardiovascular risk profiling, calcium score and CT-angiography results

Relation between Mild to Moderate Chronic Kidney Disease and Coronary Artery Disease Determined with Coronary CT Angiography

BACKGROUND: Both end-stage and milder stages of chronic kidney disease (CKD) are associated with an increased risk of adverse cardiovascular events. Several studies found an association between decreasing renal function and increasing coronary artery calcification, but it remains unclear if this association is independent from traditional cardiovascular risk factors. Therefore, the aim of this study was to investigate whether mild to moderate CKD is independently associated with coronary plaque burden beyond traditional cardiovascular risk factors. METHODS: A total of 2,038 patients with symptoms of chest discomfort suspected for coronary artery disease underwent coronary CT-angiography. We assessed traditional risk factors, coronary calcium score and coronary plaque characteristics (morphology and degree of luminal stenosis). Patients were subdivided in three groups, based on their estimated glomerular filtration rate (eGFR) Normal renal function (eGFR ≥90 mL/min/1.73 m(2)); mild CKD (eGFR 60–89 mL/min/1.73 m(2)); and moderate CKD (eGFR 30–59 mL/min/1.73 m(2)). RESULTS: Coronary calcium score increased significantly with decreasing renal function (P<0.001). Coronary plaque prevalence was higher in patients with mild CKD (OR 1.83, 95%CI 1.52–2.21) and moderate CKD (OR 2.46, 95%CI 1.69–3.59), compared to patients with normal renal function (both P<0.001). Coronary plaques with >70% luminal stenosis were found significantly more often in patients with mild CKD (OR 1.67 (95%CI 1.16–2.40) and moderate CKD (OR2.36, 95%CI 1.35–4.13), compared to patients with normal renal function (both P<0.01). After adjustment for traditional cardiovascular risk factors, the association between renal function and the presence of any coronary plaque as well as the association between renal function and the presence of coronary plaques with >70% luminal stenosis becomes weaker and were no longer statistically significant. CONCLUSION: Although decreasing renal function is associated with increasing extent and severity of coronary artery disease, mild to moderately CKD is not independently associated with coronary plaque burden after adjustment for traditional cardiovascular risk factors