The added value of renal function study in the management of ACS
JUAN CARLOS CABRERA, MARÍA CONSTANZA LUCIARDI
3era Cátedra de Patología y Clínica Médica. Facultad de Medicina
Cátedra de Práctica Profesional. Facultad de Bioquímica Química
Universidad Nacional de Tucumán (UNT)
(4000) San Miguel de Tucumán, Argentina E-mail
Recibido 11-SET-2018 – ACEPTADO el 21-SETIEMBRE-2018.
There are no conflicts of interest to disclose.
Randomized clinical trials (RCTs) are the gold standard to evaluate medical care interventions and the cornerstone for evidence-based medicine .
It is known that in RCTs, the populations of elderly patients, women and individuals with impaired renal function are underrepresented, so it is possible that in these populations, clinical trials do not have enough power to draw conclusions due to the low number of enrolled patients. Real-world evidence is considered a useful tool to supplement the data gathered by RCTs .
In the last 30 years, chronic kidney disease (CKD) has remarkably changed from the epidemiological point of view, from classical nephropathies of low incidence (glomerulopathies, cystic diseases, interstitial nephritis, etc.) to this date, when ageing, hypertension, diabetes and vascular disease reached such predominance that a significant percentage of the population is affected, and therefore, have contributed to nephrological disorders with CKD expanding exponentially .
In turn, it is necessary to highlight the scarcity of data for Latin America, in terms of prospective registries of renal function impairment (RFI) in acute coronary syndromes (ACS) as stated in the paper by Bono et al, recently published in a previous issue of this Revista, “Renal failure and myocardial infarction: A prognostic marker? SAC-FAC Argentine Registry of Acute Myocardial Infarction.”  See the paper published
In this scenario this paper acquires great significance; all the more so when we evaluate the number of patients included in it (1,402 patients) and the extension and heterogeneity of the sample, including 247 reference centers that cover the whole country, in a joint study of the Federación Argentina de Cardiología (FAC) and the Sociedad Argentina de Cardiología (SAC).
The unequivocal evidence of high risk of severe clinical events (heart failure, cardiogenic shock, heart arrest, bleeding with increased mortality) in patients with renal function impairment, <60 ml/min of creatinine clearance (CrCl), who present ST-segment elevation myocardial infarction (STEMI) as a conclusion of the study, deserves a thorough analysis to prepare more efficient protocols for the identification of RFI in the admission and follow-up of these patients.
As a contribution, maybe it would be convenient to have statistics on glomerular filtration rate (GFR) data using the MDRD  or CKD-EPI  formulas, that although not being as accurate as insulin clearance , that cannot be applied in any prospective clinical trial with a reasonable number of patients, and much less in daily practice, would yield more certainty than the Cockroft and Gault formula, which by a similarity in results to 24 h creatinine clearance overestimates GFR from 7% to 20% .
Microalbuminuria, undisputable indicator of endothelial dysfunction, and therefore, of cardiovascular risk, besides expressing measurable renal impairment progression , is currently part of the categorization in stages and degrees of renal impairment in a classification of relative risk added to the degree of renal dysfunction of the KDIGO 2009 guidelines, corroborated in 2011 . Figure 1. This classification, which adds to the glomerular filtration rate data, the microalbuminuria/creatinuria quotient, in a single urine sample expressed in mg/gr (described as albuminuria stages), would be very useful if it could be turned into a protocol in the future, given that microalbuminuria is linked to vascular phenomena in general, and much more so to endothelial dysfunction, a primary element of ACS.
In regard to the data obtained in this presentation, group III is quite remarkable, as they are the patients with less renal impairment (CrCl ≥60 ml/min) but with a high incidence of smoking (73.9%) and a relatively low percentage of COPD (3.4%) in comparison to the higher percentage of COPD in the other 2 groups (7.0% for group I and 7.7% for group II).
On the other hand, the development of acute renal failure in patients who undergo angioplasty, included in the extensive chapter on renal impairment by contrast with its high incidence of in-hospital mortality, much more so when it is necessary to replace renal function by dialytic processes (34% of mortality) requires a particular analysis of the co-morbidities present, of the type and amount of contrast to be used according to the estimated renal function, and of a monitored follow-up of evolution of creatinine in blood , even more so knowing the probability of its increase in up to 7 to 10 days after using contrast.
In brief, this study is considered an excellent contribution with conclusions that show the high risk that renal patients with ACS present, requiring to continue with the search to improve more admission, follow-up and treatment protocols, contemplating the precautions necessary as accurately as possible, to improve the prognosis of this immense range of patients (20% of patients admitted in the report) with renal function impairment suffering STEMI.
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