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Table of Contents
RESEARCH ARTICLE
Year : 2018  |  Volume : 3  |  Issue : 1  |  Page : 15-20

Prognostic impact on Type B acute aortic dissection with renal insufficiency: A single-center study


Department of Cardiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi 830011, China

Date of Web Publication16-May-2018

Correspondence Address:
Xiang Ma
Department of Cardiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi 830011
China
Yi-Tong Ma
Department of Cardiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi 830011
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cp.cp_6_18

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  Abstract 


Aims: The aim was to study the impact of renal insufficiency on type B acute aortic dissection (AAD), in terms of in-hospital mortality and long-term survival. Materials and Methods: A total of 241 consecutive patients with type B AAD from 2007 to 2014 were enrolled. Based on estimated glomerular filtration rate, two groups were formed: Group A, with e-GFR <60 ml/min/1.73 m2 and Group B, with e-GFR ≥60 ml/min/1.73 m2 and were compared. Logistic regression and Cox regression analyses were used to identify predictors of in-hospital mortality, mortality during follow-ups, and long-term survival. Results: There was no significant difference in general characteristics and hemodynamic status between the two groups (P > 0.05). Both groups received main cardiovascular drugs and/or interventional therapies (P > 0.05). Group A had longer coronary care unit stays than Group B (P < 0.05). Multivariate logistic regression model showed white blood cell (WBC) count (odds ratio [OR], 1.107; 95% confidence interval [CI], 1.016–1.206; P < 0.05), e-GFR < 60 ml/min/1.73 m2 (OR, 4.809; 95% CI, 1.716–13.480; P < 0.05), and in-hospital hypotension (OR, 13.87; 95% CI, 2.544–75.591; P < 0.05) as significant predictors for in-hospital mortality. This was also significant in Cox regression analysis: WBC count (Hazard ratio (HR), 1.108; 95% CI, 1.029–1.194, P < 0.05), e-GFR <60 ml/min/1.73 m2 (HR, 2.572; 95% CI, 1.014–6.524; P < 0.05), and in-hospital hypotension (HR, 3.309; 95% CI, 1.133–9.666; P < 0.05). Kaplan–Meier analysis showed Group A having much lower cumulative survival than Group B. Conclusion: This study shows that moderate-to-severe renal insufficiency is an independent predictor of mortality in type B AAD both during hospital stay and on subsequent follow-ups.

Keywords: Estimated glomerular filtration rate, renal insufficiency, type B aortic dissection


How to cite this article:
Bai X, Wang BZ, Ujit K, Yu ZX, Zhao Q, Ma X, Ma YT. Prognostic impact on Type B acute aortic dissection with renal insufficiency: A single-center study. Cardiol Plus 2018;3:15-20

How to cite this URL:
Bai X, Wang BZ, Ujit K, Yu ZX, Zhao Q, Ma X, Ma YT. Prognostic impact on Type B acute aortic dissection with renal insufficiency: A single-center study. Cardiol Plus [serial online] 2018 [cited 2018 Jul 20];3:15-20. Available from: http://www.cardiologyplus.org/text.asp?2018/3/1/15/232552

Xue Bai and Bao-Zhu Wang shared joint first authorship.





  Introduction Top


Moderate-to-severe renal insufficiency may be asymptomatic and neglected, if not assessed routinely. Studies show that individuals with renal insufficiency have approximately three-fold increased risk of cardiovascular mortality compared with their counterparts with normal renal function.[1]

Aortic dissection is a catastrophic cardiovascular disease with high morbidity and mortality.[2],[3] It has also been reported that acute renal failure is associated with significant morbidity in aortic dissection. A few studies have taken insights into the impact of renal insufficiency on the prognosis of aortic dissection.[4] Type B acute aortic dissection (AAD) is often successfully managed medically with low in-hospital mortality rate compared to type A AAD.[5] However, the long-term prognosis of type B AAD is associated with both higher morbidity and mortality.[6],[7],[8],[9]

Mikio et al. found renal insufficiency on admission as an independent predictor of in-hospital mortality in type B AAD. They believed that high-risk patients could be identified by calculating estimated glomerular filtration rate (eGFR).[10] However, this was a single-centered study and was limited to prognostic impact of renal insufficiency during admission only and that it did not provide information on mid- to long-term survival outcomes. Our aim is to study the prognostic impact of renal insufficiency both during admission and on subsequent follow-ups of type B AAD. We believe that renal insufficiency not only has impact on in-hospital mortality, but also on long-term survival outcomes.


  Materials and Methods Top


Study participants

This study was performed in the First Affiliated Hospital of Xinjiang Medical University from October 2007 to January 2014, approved by an Ethics committee. Written informed consent was obtained from all the study participants. Participants with confirmed diagnosis of Stanford Type B AAD with contrast computed tomography showing dissected descending thoracic aorta containing both true and false lumens were enrolled in the study. Participants whose initial presentation were >14 days on hemodialysis, whose renal arteries were narrowed or obstructed, and participants who were lost during follow-ups were not included. Standardized data recorded during hospitalization, including demographics, hemodynamics, laboratory data, cardiovascular risk factors, cardiovascular history, prior cardiac surgery history, medications on discharge, angiographic features, treatment options (including revascularization by angioplasty), and early outcomes and in-hospital mortality including length of hospital stay (ward plus coronary care unit [CCU]) were thoroughly analyzed. Adverse events included were acute renal failure, cardiogenic shock, hypotension, and aortic rupture. Out of 393 participants with Stanford type B AAD, 241 were enrolled in this study. Those remaining, whose initial presentation was of >14 days (n = 51), on hemodialysis (n = 11), and incomplete information (n = 59), were excluded from the study.

eGFR is a widely recognized marker to evaluate renal function, calculated using Modification of Diet in Renal Disease (MDRD) equation as follows: c- aGFR (ml/min/1.73 m 2) = 186 × Pcr −1.154 × age −0.203 × 0.742 (if female) × 1.233 (if Chinese) (Pcr, equals to serum creatinine). Race is an important determinant of GFR estimation. In the previous study, the performance of the abbreviated MDRD equation was tested in a group of Chinese participants with CKD. Results showed that the equations underestimated residual glomerular filtration rate (rGFR) in near-normal renal function and overestimated rGFR in advanced renal failure. Therefore, 1.233 was added as a racial factor for Chinese participants.[11]

Mean follow-up time was 585 days following discharge. The main parameter evaluated was general mortality during hospital stay and on subsequent follow-ups.

The study population was divided into two groups, according to e-GFR: Group A, with e-GFR <60 ml/min/1.73 m 2 (n = 49) and Group B, with e-GFR ≥60 ml/min/1.73 m 2 (n = 192). The 60 ml/min cutoff, in accordance with the current National Kidney Foundation definition of significant renal failure, was used, as many studies have shown a significant increase in cardiovascular events below this threshold.[12]

Statistical analysis

Quantitative variables with normal distribution were presented as mean ± standard deviation and analyzed using t-test or ANOVA test, while nonnormal distribution was presented as median (interquartile range) and analyzed using Mann–Whitney U-test. Qualitative variables were presented as percentages with regard to e-GFR classification and analyzed using Chi-square test. Kaplan–Meier plot was used for describing mortality process by different e-GFR groups and log-rank test was used to compare the survival curves. Logistic regression model was used to identify the predictors of in-hospital death, whereas Cox regression analysis was used to identify the risk factors of survival time during follow-up. Age, sex, hypertension, dyslipidemia, diabetes, smoking, atherosclerosis, acute renal failure, eGFR <60 ml/min/1.73 m 2, renal arteries involved, white blood cell (WBC) on admission, and cardiogenic shock were considered independent variables in multivariate analyses. All P values were bilateral and considered statistically significant if P < 0.05. Stata 11.0 software (Stata Corp LP, College Station, TX, USA) was used for analysis.


  Results Top


Study participants and baseline characteristics

There was no significant difference, in terms of age and sex between the two groups (P > 0.05). Thirty-three participants (13.50%) had diabetes, 184 (76.15%) had hypertension, 145 (60.0%) had dyslipidemia, and 123 (51.05%) had a history of smoking. Again, there was no significance between the two groups (P > 0.05) [Table 1].
Table 1: General characteristics of participants according to estimated glomerular filtration rate

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Heart rate on admission was 83.14 ± 15.21 bpm, systolic blood pressure was 147.33 ± 28.28 mmHg, and diastolic blood pressure was 87.63 ± 19.05 mmHg. WBC count on admission was significantly higher with e-GFR <60 ml/min/1.73 m 2 than e-GFR ≥60 ml/min/1.73 m 2 (P< 0.05). There was no significant difference in lipid levels between the two groups (P > 0.05). Overall, e-GFR was 89.39 ± 37.82 ml/min/1.73 m 2, with uric acid 322.76 ± 112.42 umol/L and urea 6.12 ± 3.45 umol/L [Table 2].
Table 2: Hemodynamics, laboratory data, medications, angiographic features, and therapies according to estimated glomerular filtration rate

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All participants were initially treated with intense medical therapy that focused on lowering BP. Among them, 52 participants (21.67%) continued on medical therapy, 181 (75.00%) underwent interventional procedure followed by medical therapy, and 8 (3.33%) underwent open-heart surgery. Both groups were similar to each other in terms of therapy options (P > 0.05) [Table 2].

Duration of hospital stays for Group A was 14.5 (7.5–23.25) days and Group B was 13 (9–19) days. There was no significant difference (P > 0.05) in terms of hospital stay. Length of CCU stay for Group A was longer than Group B (10.5 [6.5–18.5] versus 8 [4–12]) days (P< 0.05). The rate of acute renal failure with eGFR < 60 ml/min/1.73 m 2 was higher than that of eGFR ≥60 ml/min/1.73 m 2 (P< 0.05). In-hospital complications, such as cardiogenic shock, hypotension, aortic rupture, and in-hospital mortality, were similar in both groups (P > 0.05) [Table 3].
Table 3: Early outcomes and in-hospital mortality according to estimated glomerular filtration rate

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Importance of renal insufficiency versus in-hospital mortality

Hospital mortality in Group A was 10.20% and Group B was 6.25%. Logistic analysis was used to investigate the importance of renal dysfunction versus in-hospital mortality. Variables such as age, sex, hypertension, dyslipidemia, diabetes, smoking, atherosclerosis, acute renal failure, eGFR <60 ml/min/1.73 m 2, narrowed or obstructed renal arteries, WBC on admission, and cardiogenic shock were analyzed. WBC count (odds ratio [OR], 1.107; 95% confidence interval [CI], 1.016–1.206; P < 0.05), e-GFR < 60 ml/min/1.73 m 2 (OR, 4.809; 95% CI, 1.716–13.480; P < 0.05), and in-hospital hypotension (OR, 13.87; 95% CI, 2.544–75.591; P < 0.05) were found to be significant predictors for in-hospital mortality [Table 4].
Table 4: Logistic regression model for prediction of in-hospital death

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Prognostic impact of renal insufficiency versus follow-up mortality

Mean follow-up period was 585 days following discharge. Variables such as age, sex, hypertension, dyslipidemia, diabetes, smoking, atherosclerosis, acute renal failure, eGFR <60 ml/min/1.73 m 2, narrowed or obstructed renal arteries, WBC on admission, and cardiogenic shock were analyzed. WBC count on admission (HR, 1.108; 95% CI, 1.029–1.194, P < 0.05), e-GFR <60 ml/min/1.73 m 2 (HR, 2.572; 95% CI, 1.014–6.524; P < 0.05), and in-hospital hypotension (HR, 3.309; 95% CI, 1.133–9,666; P < 0.05) showed significance. Kaplan–Meier survival curve showed that Group A had much lower cumulative survival rate than Group B [Figure 1].
Figure 1: Kaplan–Meier curve for overall mortality in patients with Stanford type B acute aortic dissection stratified according to estimated glomerular filtration rate (ml/min/1.73 m2) on admission

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  Discussion Top


It is obvious that those with cardiovascular diseases with moderate-to-severe renal insufficiency are more likely to have higher in-hospital mortality and more frequent adverse events.[13] Little is known about the impact of renal dysfunction on the outcome of aortic dissection, especially type B AAD.

This study was aimed at evaluating type B AAD participants with impaired renal function during admission and its impact on in-hospital mortality and long-term survival. We found that renal insufficiency is an independent predictor of in-hospital mortality and long-term survival.

Those with chronic kidney disease have complex clinical conditions and poor prognosis and are difficult to treat.[14],[15],[16],[17] Liu et al. found that in elderly patients with acute coronary syndrome, renal insufficiency is associated with advanced age, diabetes, hypertension, and cardiac dysfunction, which cannot be treated aggressively.[18] However, our study showed no significant difference between the two groups, in terms of age and cardiovascular risk factors. Both groups received same category of treatment. This possibility may be due to the majority of participants having mild renal insufficiency. Based on this, relations with age and cardiovascular risk factors for severe renal insufficiency may not be applicable for mild renal dysfunction conditions. This is why participants of Group A were not older and did not have higher rates of diabetes, hypertension, and cardiac dysfunction than Group B.

It is well established that in the pathogenesis of aortic dissection, hypertension played an important role. Some connective tissue and metabolic diseases also increase the risk of aortic dissection at an early age. Endothelial dysfunction, activation of renin–angiotensin system, oxidative stress, elevated asymmetric dimethylarginine, low-grade inflammation with increased circulating cytokines, and dyslipidemia lead to tear of the aorta.[19],[20],[21]

AAD is associated with inflammatory reaction as evidenced by significant elevation in inflammatory markers, including C-reactive protein (CRP).[22],[23],[24],[25],[26],[27] Sakakura et al. found that peak CRP is a strong predictor for adverse long-term events in patients with type B AAD.[28] Our study showed significant difference in the level of WBC count between Groups A and B and higher WBC count tend to be associated with poor prognosis both during hospital stay and on subsequent follow-ups, which is consistent with the concept that AAD is associated with inflammatory reaction. Careful clinical follow-up may be warranted in those with high WBC count during admission.

Another important finding in our study is that in-hospital hypotension can also provide prognostic significance for in-hospital mortality and long-term survival of type B AAD. Suzuki et al. analyzed the clinical features, diagnoses, imaging findings, and management and in-hospital outcomes of patients with type B AAD. Factors associated with in-hospital mortality and their quantitative relative risks were also assessed to aid in risk stratification and decision-making. The Deadly Triad also had identified hypotension and shock, absence of chest and back pain on presentation, and branch vessel involvement to be associated with increased risk of in-hospital mortality.[4]

Limitations

This is a single-centered retrospective study, which may not necessarily be applicable to the general population. Second, we could have favored chronic kidney disease and acute kidney injury, as kidney function was assessed only during admission. Third, we assessed in-hospital death as an outcome parameter. Although mortality assessment is necessary and important in the management of disease, this may not be sufficient for full evaluation in considerable factors such as nonfatal adverse events.


  Conclusion Top


The present study demonstrates that moderate-to-severe renal dysfunction is an independent predictor of in-hospital mortality and long-term survival for type B AAD. Besides, in-hospital hypotension and raised WBC on admission present significant influence on mortality and long-term survival. Early identification of these high-risk patients and strategic management may improve mortality and long-term survival. However, a large multicenter prospective study is needed to address the best approach for evaluating the predictors on long-term survival.

Acknowledgment

We would like to acknowledge Ang Li, Mayila, Wei Zhu, and Ting Zou for preparation and collection of data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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