Cardiac Autonomic Neuropathy Predicts All-Cause and Cardiovascular Mortality in Patients With End-Stage Renal Failure: A 5-Year Prospective Study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: End-stage renal failure (ESRF) (n=123). Intervention: Cardiac autonomic neuropathy (CAN) assessed by the 4 standardized Ewing tests vs. Absence of cardiac autonomic neuropathy (CAN). Primary outcome: All-cause mortality (HR 2.977, 95% CI 1.478-5.997, p=0.002).

Q: What does this research mean for the field?

Cardiac autonomic neuropathy is an independent predictor of all-cause and cardiovascular mortality in patients with end-stage renal failure. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

D. Doulgerakis; Ioannis Moyssakis; Chris J. Kapelios; Ioanna Eleftheriadou; Stamatia Chorepsima; Spyridon Michail; Nikolaοs Tentolouris

doi:10.1016/j.ekir.2017.03.002

March 16, 2017Kidney International ReportsOpen Access

Cardiac Autonomic Neuropathy Predicts All-Cause and Cardiovascular Mortality in Patients With End-Stage Renal Failure: A 5-Year Prospective Study

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Key result

Cardiac autonomic neuropathy is linked to ~3-fold higher all-cause mortality in end-stage renal failure.

HR 2.977
95% CI 1.478-5.997
P=0.002
n=123

Figures

Why the study?

Does the presence of cardiac autonomic neuropathy (CAN) and impaired left ventricular function predict all-cause and cardiovascular mortality in patients with end-stage renal failure?

Key Points

To evaluate the prospective prognostic value of left ventricular function and cardiac autonomic neuropathy for all-cause and cardiovascular mortality in patients with end-stage renal failure.
Prospective cohort study of 133 recruited patients with end-stage renal failure, with 123 (92.5%) completing follow-up over a mean duration of 4.9 ± 2.6 years.
Left ventricular function was assessed via echocardiography, and cardiac autonomic function was evaluated using Ewing's battery of four standardized tests.
Among 123 analyzed patients, 70 (57.9%) had cardiac autonomic neuropathy, with 69 all-cause and 36 cardiovascular deaths recorded over follow-up.
Cumulative survival was lower in patients with cardiac autonomic neuropathy compared to those without (32.9% vs 60.8%, P=0.001), and in patients with left ventricular ejection fraction ≤50% versus >50% (30% vs 55.4%, P=0.004).
Multivariate and competing risk analyses confirmed that presence of cardiac autonomic neuropathy and age were independent predictors of both all-cause and cardiovascular mortality.

Study Design

Type

Cohort (n=123)

Multicenter

No

Structured PICO

Does the presence of cardiac autonomic neuropathy (CAN) and impaired left ventricular function predict all-cause and cardiovascular mortality in patients with end-stage renal failure?

P

Population

123 adults with end-stage renal failure (51.2% on hemodialysis, mean age 59.5 years, 35.8% female), followed for a mean of 4.9 years.

E

Exposure

Presence of cardiac autonomic neuropathy (CAN), diagnosed as at least 2 abnormal tests out of the battery of 4 standardized Ewing tests (deep breathing E/I index, lying-to-standing 30:15 ratio, Valsalva ratio, and orthostatic hypotension change in SBP), and left ventricular function indexes (LVEF, LVMI) assessed by 2D and Doppler echocardiography.

C

Comparator

Absence of cardiac autonomic neuropathy (CAN <2 abnormal Ewing tests) and higher left ventricular ejection fraction (LVEF >50%).

O

Outcome

All-cause mortality over a mean follow-up of 4.9 ± 2.6 years (median 5.7 years).hard clinical

Main Result

Hazard Ratio: 2.977 (95% CI 1.478–5.997)

p-value: p=0.002

Limitations

Small number of patients
All patients had end-stage renal failure, so results cannot be extrapolated to patients in earlier stages of chronic kidney disease
10 of 133 recruited patients attended only the baseline visit and were lost to follow-up
Small number of patients (n=123 analyzed)
Results limited to patients with end-stage renal failure and cannot be extrapolated to earlier stages of chronic kidney disease
Single-center study with 10 patients lost to follow-up after baseline visit

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Implication

Cardiac autonomic neuropathy assessed via bedside Ewing tests is a strong, independent predictor of both all-cause and cardiovascular mortality in patients with end-stage renal failure and can be used for clinical risk stratification.

Abstract

INTRODUCTION: Chronic renal disease is associated with increased cardiovascular (CV) mortality. Cardiac autonomic neuropathy (CAN) is predictive of mortality for diseases that affect the autonomic nervous system. We prospectively evaluated the prognostic value of indexes of left ventricular (LV) function and CAN in all-cause and CV mortality of patients with end-stage renal failure (ESRF). METHODS: A total of 133 patients with ESRF were recruited. LV function was evaluated by echocardiography, whereas cardiac autonomic function was assessed using the battery of the 4 standardized tests proposed by Ewing. RESULTS: A total of 123 of 133 (92.5%) patients completed the study and were followed for a mean of 4.9 ± 2.6 years. Mean LV ejection fraction (LVEF) was 50.9 ± 6.9%, whereas 70 (57.9%) patients had CAN. Sixty-nine all-cause and 36 CV deaths were recorded. The survival rates at 3, 5, and 7 years were 77.2%, 57.4%, and 33.7%, respectively. Multivariate analysis after adjustment for waist circumference, current smoking, history of diabetes, and coronary artery disease demonstrated that the only independent predictors of all-cause mortality during follow-up were age, serum triglycerides, LVEF, and presence of CAN. Competing risk regression analysis, after adjusting for waist circumference, coronary heart disease, serum glucose, and triglycerides, indicated that age and presence of CAN were independent risk factors for CV mortality. DISCUSSION: Age and presence of CAN are independent predictors of all-cause and CV mortality in patients with ESRF. The functionality of the cardiac autonomic nervous system activity can be used for the risk stratification in patients with ESRF.

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Cite This Study

Doulgerakis et al. (2017) conducted a cohort in End-stage renal failure (ESRF) (n=123). Cardiac autonomic neuropathy (CAN) assessed by the 4 standardized Ewing tests vs. Absence of cardiac autonomic neuropathy (CAN) was evaluated on All-cause mortality (HR 2.977, 95% CI 1.478-5.997, p=0.002). Cardiac autonomic neuropathy independently predicted all-cause mortality (adjusted HR 2.977, 95% CI 1.478-5.997, p=0.002) and CV mortality (HR 2.360, p=0.049) in end-stage renal failure patients.

synapsesocial.com/papers/6a7c5e7a8ded3476ac085a00 https://doi.org/10.1016/j.ekir.2017.03.002

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Cardiac Autonomic Neuropathy Predicts All-Cause and Cardiovascular Mortality in Patients With End-Stage Renal Failure: A 5-Year Prospective Study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Cardiac Autonomic Neuropathy Predicts All-Cause and Cardiovascular Mortality in Patients With End-Stage Renal Failure: A 5-Year Prospective Study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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